Euthanasia Consent Form
Please fill out this form in entirety to ensure we can provide your pet with the best possible care.
Pet's Name
*
First Name
Last Name
Who is your pet seeing today?
Please Select
Dr. Rachael Kuhn-Siegel
Dr. Jaclyn Hoerr
The Patient Care Team
Relief Doctor
Your Name
*
First Name
Last Name
Email
example@example.com
Has your pet bitten anyone in the last 10 Days?
Yes
No
Will you be wanting a necropsy? Please initial below If you would like us to do one.
(This can be informative test that helps us get a diagnosis to find out what has happened but sometimes it does not provide us with all the answers we would like. There are added charges to this service if you would like a report of the necropsy)
Would you like Cremation of your Pet's remains?
Yes
No
Unsure
Do you have any special directions that you would like adhered to?
Will you be paying with a credit or debit card?
Yes
No
Authorizations
I, the undersigned, am the owner (or duly authorized agent for the owner) of the animal described above. I hereby consent to and order euthanasia (humane death) to be performed on this animal. It is my desire to provide for my pet a decent and humane after-death care, complying with all legal requirements of the area. I authorize the attending veterinarian and staff to take charge of my pet’s remains in accordance with hospital policy, releasing the hospital, veterinarians, and agents from any and all liability for performing said after-death care.
*
Initial
Pet Cremation Authorization I, the undersigned, am the owner (or duly authorized agent for the owner) of the animal described above. I hereby convey the remains of my pet to Prairie Animal Hospital to arrange for the cremation and disposition of said pet. I also certify that my pet’s remains do not contain a pacemaker, radioactive implant, or any other device that could be harmful to the crematory and that they are safe to cremate.
*
Initial
Would you like another paw Print made for $15? Please choose an option of how many paw prints your would like
None Free
Original Free
Second one $15
Three Pawprints $30
Please indicate your decision for care of remains by selecting below?
Group cremation (remains will NOT be returned)
Individual cremation (remains will be returned to PAH for pick up by owner)
Private cremation (remains will be returned to PAH for pick up by owner)
*
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