Euthanasia Authorization Form

Euthanasia Authorization Form
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Pet’s Name*
Presenting Condition/Reason for Euthanasia Request*
Date of Birth*

MonthDayYear
Patient’s Date of Birth
Species*
Species
Breed*
Breed
Color*
Color
Sex*
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 ashesCremation with no return of ashes. My pet's remains will not be retuned to meHome Burial
Choose Your Preferred Urn (no additional fee for the below urns)*

Blue Scattering Tube Urn with Paw PrintsCedar Memorial UrnDecorative Metal Urn (BLUE)Decorative Metal Urn (TAN)Hand-carved Rosewood UrnNo UrnRemembrance UrnSerenity Photo UrnI 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, VAI would like my pet's cremains shipped to my homeI will pick up my pet’s cremains from my primary veterinary clinic
Name of Your Primary Veterinary Clinic*
Keepsake & Memorial Items
Clay Paw Print in Black Frame     # Clay Paw Print in Black Frame
Clay Nose Print in Black Frame      # Clay Nose Print in Black Frame
PawPals Impression Kit     # PawPals Impression Kit(s)
Ink Nose Print     # Ink Nose Print(s)
Ink Paw Print# Ink Paw Print(s)
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.

Initials* I have read and understand the above authorization for humane euthanasia and release all liability as stated above.

I First & Last Name of Owner/Authorized Agent* 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.
Signature*
Signature*

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Date*

MonthDayYear
Date
Electronic Signature Agreement

By signing and typing my name below I agree to signing this authorization form electronically
Name*

First NameLast Name
Signature*

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Euthanasia Authorization Form

Aftercare Services

Keepsake & Memorial Items

Authorization for Humane Euthanasia

Electronic Signature Agreement