Euthanasia Consent Form

Client Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Alternate Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

Pet Name*

Type of Pet

DogCatOther

Sex

Male (intact)Male (neutered)Female (intact)Female (neutered)

Breed*

Color*

Birth Date or Age

Chip Number

AUTHORIZATION*

I, the undersigned, certify that I am the owner (or authorized agent of the owner) of the animal described above. I request, consent to, and order euthanasia to be performed on the described animal.I, the undersigned, give Dr. Whitehouse (and her agents and representatives) full and complete authority to euthanize and cremate said animal in a humane manner and in accordance with the rules and regulations of this establishment. Furthermore, I release the veterinarian, representatives and clinic from any and all liability of this euthanasia.I understand that euthanasia is the act of ending the life of an animal in a painless way to prevent any unnecessary suffering.

Signature*

Signature Date*

Date