Euthanasia Consent Form
Client Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / 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
Dog
Cat
Other
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
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
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