Euthanasia Consent Form
Owner Information
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pet’s Name
*
Age / Date of Birth
*
Pet’s weight (lbs only)
*
Species
Please Select
Dog
Cat
Other
Breed
*
Sex
*
Male
Female
Spayed / Neutered?
*
Yes
No
Is your pet up-to-date on Rabies Vaccination?
*
Yes
No
To the best of your knowledge, has your pet bitten any person or other animal in the last 10 days?
*
Yes
No
Reason for Euthanasia
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Primary Vet Clinic
*
Would you like your regular veterinarian to be notified of your pets passing?
*
Yes
No
How did you hear about us?
Aftercare
*
I will arrange my own aftercare service. If I choose to burry my pet at home, I understand it is my responsibility to contact my local city/county for regulations. Burying a euthanized pet can put other pets and wildlife at risk for death if not done properly.
Communal Cremation with Paw Prints Crematory (Ashes will NOT be returned to you, but will be scattered in a dignified manner.)
Individual or Private Cremation with Paw Prints Pet Crematory. Ashes will be returned to your primary veterinarians office, or they can be picked up directly from Paw Prints Pet Crematory if preferred. For more information on additional memorial options, please visit www. Petangelmemorialcenter.com
Will someone be able to assist the care provider with the stretcher?
*
Yes
No
Please choose one of the following payment methods:
*
Cash (exact amount as cash is not carried with the provider)
Check
Credit Card
Venmo
PayPal
Please provide any additional comments you would like to share with the care team.
I, the undersigned, certify that I am the owner or authorized agent of the owner of the above-named animal and hereby give Coello Veterinary Services, LLC, doing business as Hearts at Home House Call Veterinary Care, and its doctors, staff, employees, agents, and independent contractors full and complete authority to perform euthanasia (humane termination of life) of my pet. I fully release and hold harmless the attending veterinarian, all staff members, assistants, agents, and contractors from any and all liability or claims arising from or related to the performance of said euthanasia.Arrangements for aftercare will be carried out according to my wishes as documented above. If home burial or personal disposal is chosen, I agree to comply with all local, state, and federal regulations regarding the proper handling and disposition of remains. To the best of my knowledge, the information I have provided on this form is accurate and true. I also certify that this animal has not bitten any human or other animal within the past ten (10) days.
*
I agree
By signing your name on this document, you agree that your electronic signature is a legally binding equivalent to your handwritten signature. You also confirm that you are the individual named in this electronic signature and that you are authorized to sign the document.
*
I agree
Signature
*
Date
*
-
Month
-
Day
Year
Date
Drugs used and any additional comments per EKC
Submit
Submit
Should be Empty: