Euthanasia Consent Form

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 NameLast Name
Who is your pet seeing today?
Your Name*

First NameLast Name
Email
example@example.com
Has your pet bitten anyone in the last 10 Days?

YesNo
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?

YesNoUnsure
Do you have any special directions that you would like adhered to?
Will you be paying with a credit or debit card?

YesNo
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
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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My Products

Dog or Cat Euthanasia with Paw Print$159.00

Enter description

Quantity
Item subtotal:$0.00

Cremation$293.55

Cremation Options

Type of Cremation
Item subtotal:$0.00

Total $0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Should be Empty:

Euthanasia Consent Form

Authorizations