Euthanasia Authorization Form

Euthanasia Authorization Form
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Pet’s Name*
Presenting Condition/Reason for Euthanasia Request*
Date of Birth*

MonthDayYear
Patient’s Date of Birth
Species*
Species
Breed*
Breed
Color*
Color
Sex*
Sex
Pet’s Weight (in pounds)*
Name of Your Primary Veterinary Clinic*
Aftercare Services
I request that this animal's remains be cared for in the following manner:*

Private cremation with return of ashesCremation with no return of ashes. My pet's remains will not be retuned to meHome Burial
Choose Your Preferred Urn (no additional fee for the below urns)*

Blue Scattering Tube Urn with Paw PrintsCedar Memorial UrnDecorative Metal Urn (BLUE)Decorative Metal Urn (TAN)Hand-carved Rosewood UrnNo UrnRemembrance UrnSerenity Photo UrnI plan to order a custom urn directly through Agape Pet Services of Virginia: 804-737-8400
Return of Pet’s Cremains*

I will pick the cremains at Agape Pet Services: 1001 Techpark Place, Sandston, VAI would like my pet's cremains shipped to my homeI will pick up my pet’s cremains from my primary veterinary clinic
Would you like us to provide a Euthabag - a respectful & ecological way to bury your beloved pet?
Euthabag*

Yes, I would like a Euthabag for my beloved pet.No
Keepsake & Memorial Items
Clay Paw Imprint with Faux Leather Case # of clay paw Imprints
Clay Nose Imprint with Faux Leather Case # of Clay Nose Imprints
PawPals Impression Kit # of PawPals Impression Kits
Ink Nose Print

   # of Ink Nose Prints
Ink Paw Print

# of Ink Paw Prints
Authorization for Humane Euthanasia
I am the legal owner or duly authorized agent for the owner of the animal described above and do hereby give House Call Vet RVA and the veterinarian licensed to perform euthanasia, Dr. Kaitlyn Hemsley, full and complete authority to euthanize and dispose or arrange for cremation of said animal in a humane manner. I hereby forever release Dr. Kaitlyn Hemsley, DVM, of the facility, House Call Vet RVA, from any and all liability for euthanasia and disposing of said animal. House Cal Vet RVA, and the licensed veterinarian performing euthanasia services, Dr. Kaitlyn Hemsley, to choose a euthanasia protocol at their sole and exclusive discretion. I understand that any questions or concerns regarding euthanasia services requested for the animal listed above should be asked prior to signing this consent.

Initials* I have read and understand the above authorization for humane euthanasia and release all liability as stated above
I Full Name of Owner/agent* do certify to the best of my knowledge the animal listed above has not bitten, seriously scratched, or exposed anyone to rabies within the past l0 days. I am aware that Virginia law requires proof of prior rabies vaccination and may require post euthanasia rabies testing of any animal who has bitten a person(s) or another animal or been exposed to a rabid animal or person(s) within the past 10 days. Remains cannot be returned after rabies testing. Ashes may be returned if requested below. Signature
Signature*

Clear
Owner/Authorized Agent
Date*

MonthDayYear
Date
Payment & Cancellation Policy
Initials* I have read, understand and agree to House Call Vet RVA, Appointment & Payment Policy.
Electronic Signature Agreement

By signing and typing my name below I agree to signing this authorization form electronically
Name*

First NameLast Name
Signature*

Clear
Owner/Authorized Agent
Type a question
Should be Empty:

Euthanasia Authorization Form

Aftercare Services

Keepsake & Memorial Items

Authorization for Humane Euthanasia

Payment & Cancellation Policy

Electronic Signature Agreement