Euthanasia Consent Form
Owner Information
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pet’s Name
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Age / Date of Birth
*
Pet’s weight
*
Species
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Breed
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Sex
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Male
Female
Spayed / Neutered?
*
Yes
No
Is your pet up-to-date on Rabies Vaccination?
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Yes
No
To the best of your knowledge, has your pet bitten any person or other animal in the last 10 days?
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Yes
No
Reason for Euthanasia
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Primary Vet Clinic
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Would you like your regular veterinarian to be notified of your pets passing?
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Yes
No
How did you hear about us?
Aftercare
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I will arrange my own aftercare service. If I choose to carry 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. Pawprintspetcrematory.com
Will someone be able to assist the care provider with the stretcher?
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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, for the above named animal, and hereby give Coello Veterinary Services, LLC and its Doctors full and complete authority to perform euthanasia (humane termination of life) of my pet. I release the Doctor, staff, and agents from any and all liability to performing said euthanasia. Arrangements for aftercare will be based on the wishes of the owner/agent and documented as selected above. If home burial or disposal is chosen, I agree to comply with all legal requirements of the area. 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 any human or other animals in the last 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: