Euthanasia Authorization Form
Name
*
Prefix
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pet’s Name
*
Presenting Condition/Reason for Euthanasia Request
*
Date of Birth
*
-
Month
-
Day
Year
Patient’s Date of Birth
Species
*
Please Select
Canine
Feline
Species
Breed
*
Breed
Color
*
Color
Sex
*
Please Select
Male
Male, Neutered
Female
Female, Spayed
Sex
Pet’s Weight (in pounds)
*
Patient’s weight in pounds
Aftercare Services
I request that this animal's remains be cared for in the following manner:
*
Private cremation with return of ashes
Cremation with no return of ashes. My pet's remains will not be retuned to me
Home Burial
Choose Your Preferred Urn (no additional fee for the below urns)
*
Blue Scattering Tube Urn with Paw Prints
Cedar Memorial Urn
Decorative Metal Urn (BLUE)
Decorative Metal Urn (TAN)
Hand-carved Rosewood Urn
No Urn
Remembrance Urn
Serenity Photo Urn
I plan to order a custom urn directly through Agape Pet Services of Virginia: 804-737-8400
Return of Pet’s Cremains
*
I will pick the cremains at Agape Pet Services: 1001 Techpark Place, Sandston, VA
I would like my pet's cremains shipped to my home
I will pick up my pet’s cremains from my primary veterinary clinic
Name of Your Primary Veterinary Clinic
*
Keepsake Items
Keepsake Items
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Ink Nose Print
Enter description
$
23.00
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Ink Paw Print
Enter description
$
23.00
Quantity
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PawPals Impression Kit
Enter description
$
35.00
Quantity
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Clay Paw Print in Black Frame
$
63.95
Quantity
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Clay Nose Print in Black Frame
$
63.95
Quantity
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Authorization for Humane Euthanasia
I am the legal owner or duly authorized agent for the owner of the animal described above and do hereby give House Call Vet RVA and the veterinarian licensed to perform euthanasia, Dr. Kaitlyn Hemsley, full and complete authority to euthanize and dispose or arrange for cremation of said animal in a humane manner. I hereby forever release Dr. Kaitlyn Hemsley, DVM, of the facility, House Call Vet RVA, from any and all liability for euthanasia and disposing of said animal. House Cal Vet RVA, and the licensed veterinarian performing euthanasia services, Dr. Kaitlyn Hemlsey, to choose a euthanasia protocol at their sole and exclusive discretion. I understand that any questions or concerns regarding euthanasia services requested for the animal listed above should be asked prior to signing this consent.
*
I have read and understand the above authorization for humane euthanasia and release all liability as stated above.
I do certify to the best of my knowledge the animal listed above has not bitten, seriously scratched, or exposed anyone to rabies within the past l0 days. I am aware that Virginia law requires proof of prior rabies vaccination and may require post euthanasia rabies testing of any animal who has bitten a person(s) or another animal or been exposed to a rabid animal or person(s) within the past 10 days. Remains cannot be returned after rabies testing. Ashes may be returned if requested below.
*
I have read and agree to the above statement and state law requirements.
Payment is due, in full, at least 24 hours prior to the appointment date/time. I assume responsibility for all charges incurred in the care of the animal. Accepted payment methods include bank transfer, Venmo, Apple Pay, Check and Cash.
*
I have read and understand the above statement.
Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
Electronic Signature Agreement
By signing and typing my name below I agree to signing this authorization form electronically
Name
*
First Name
Last Name
Signature
*
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