Euthanasia Consent

Client Information
Name

First NameLast Name
Primary Phone Number
First point of contactFormat: (000) 000-0000.
Secondary Phone Number
Backup contactFormat: (000) 000-0000.
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:
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 print
Paw prints are obtained using a media that sets with time so no baking is needed.

$10.00 Quantity

Hair clipping
Each 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.
Should be Empty:

Client Information