Euthanasia Consent Form

1

Client Full Name* This field is required.

First Name

Last Name

2

Address* This field is required.

Street Address

City

State

Zip Code

Country

3

Phone Number* This field is required.

Please enter a valid phone number.

4

Email* This field is required.

example@example.com

5

Pet's Name* This field is required.

6

Gender* This field is required.

7

Species* This field is required.

8

Breed* This field is required.

9

Approximate Age* This field is required.

10

Approximate Weight* This field is required.

11

Regular Veterinary Clinic* This field is required.

12

How did you hear about us?* This field is required.

13

Presenting Condition(s)* This field is required.Please tell us a little bit about what's going on with your pet

14

Please select the service* This field is required.

Euthanasia - humanely terminate life

My pet is already deceased- I require body care only

15

I certify that I am the owner or authorized agent of the owner, for the above-named animal. In being the owner/agent for this animal, I do hereby give Kona's Loving Paws full and complete authority to perform euthanasia services. Arrangements for aftercare will be based on the wishes of the owner/agent and documented below. I release the above-named animal to Kona's loving paws for humane euthanasia services.

16

Body Disposition Request* This field is required.

I choose to retain my pet for burial

I choose communal cremation ( ashes will NOT be returned)

I choose Private Cremation ( ashes returned in engraved wood urn, paw print, fur clipping)

17

Body disposition Request* This field is required.no euthanasia performed

I choose communal cremation ( ashes will NOT be returned)

I choose Private Cremation ( ashes returned in engraved wood urn, paw print, fur clipping)

18

If your pet is 90lbs or heavier will there be someone available to help with moving the pet into the Cremation Van? * This field is required.There will be a gurney and one additional person to help

YESNO

19

Will Someone be present to help move your pet to the Cremation Van if your pet is over 40 lbs?* This field is required.One individual and a gurney will be arriving for the pickup

YESNO

20

Please provide your custom engraving for your URN

21

Potential Hazards of Home Burial* This field is required.Please read the article regarding the potential hazards by clicking here: HAZARDS Please check with your county for home burial regulations.

I certify that I understand and accept any risk that may be associated with a home burial

22

Would you like to purchase additional Clay Paw Prints ( one is included in the private cremation packages) Each additional clay paw print may be purchased through the crematorium for $48.15 ( that's including tax) Payment will be made separately to the cremation company

YESNO

23

How many would you like to purchase?

24

To the best of my knowledge, the information I have provided on this form is true. I do also certify that this animal has not bitten, seriously scratched, or exposed anyone to rabies within the past 10 days. I understand that my wishes will be immediately carried out upon signing this agreement. Fees for these services have been explained to me and will be collected prior to the time of service.

25

I hereby provide, Kona's Loving Paws, permission to take photographs and videos of me and my pet for the purpose of posting on Kona's Loving Paws social media pages, clinic website, and marketing materials. I understand that I may revoke consent at any time by providing written notice to Kona's Loving Paws. In such instances, Kona's Loving Paws, shall remove any such social media posts as soon as reasonably possible. Any images we capture and use will be done so with the utmost respect and dignity for you and your pet, ensuring that the process is discreet and non-disruptive.

YES I give consentNO I do not give consent

26

Owner/Agent signature* This field is required.

Clear

27

Date* This field is required.

Date

28

Please verify that you are human* This field is required.

29

Would you like to purchase a Euthabag?( pet burial bag)

YESNO

30

What size bag would you like to purchase?

31

Would you like any additional hair clippings?One comes standard with your order but you may request additional ones at no charge.