Euthanasia Consent

Client Information
Name*

First NameLast Name
Primary Phone Number*
First point of contact
Secondary Phone Number
Backup contact
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Information
Name

Nickname if applicable
Age
Breed
Color
Current estimated weight in pounds*
What vet hospital/veterinarian do you use?
Does your pet have a diagnosed medical condition? What symptoms is your pet experiencing?*
Is your pet still eating food or treats?
Does your pet need assistance to stand or walk?
Has your pet ever been aggressive with people or in certain situations? Please explain.*

Euthanasia Consent and Provisions for Aftercare
In regards to the handling of my beloved pet's remains I chose one of the following:*

I will handle and take full responsibility for all aftercare arrangements myself. I am aware of any applicable laws and regulations regarding the burial of my pet and understand caution should be taken when burying so that other animals are not inadvertently exposed to the euthanasia medication.I wish to have The Last Gift arrange for my pet’s after care and chose PRIVATE cremation where my pet is cremated alone and their ashes ARE returned to me in a keepsake urn.I wish to have The Last Gift arrange for my pet’s after care and chose GROUP cremation where my pet is cremated along with other animals and their ashes will NOT be returned to me.
A clay paw print can be obtained at no charge once your pet is comfortably under anesthesia. The clipping will be placed in a white mesh bag adorned with a charm. Please let us know if you would like this service.
A hair clipping can be obtained at no charge once your pet is comfortably under anesthesia. The clipping will be placed in a white mesh bag adorned with a charm. Please let us know if you would like this service.
If you would like additional remembrance items please select below:
prevnext( X )
Clay paw printPaw prints are obtained using a media that sets with time so no baking is needed.
$10.00 Quantity

Hair clippingEach hair clipping is carefully obtained and placed in a white mesh with a small charm.
$5.00 Quantity

Total

$0.00
If you have any special requests or certain expectations please type them here and I will try my best to honor them.
I, First Name* Last Name* , attest that everything on this form is correct to the best of my knowledge on Date and that by signing below I am electing to move forward with euthanasia and aftercare.
Clear
Should be Empty:

Client Information

Patient Information

Euthanasia Consent and Provisions for Aftercare