Euthanasia Authorization Form

Date of Appointment*

Date

Owner’s Name*

First NameLast Name

Preferred Title

Partner’s Name (if applicable)

First NameLast Name

Preferred Title

Children (names & ages)

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is Mailing Address different ?*

YesNo

Mailing address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Phone Type*

Alternate Phone

Please enter a valid phone number.

Phone Type

E-mail Address*

example@example.com

Pet’s Name*

Nickname(s)

Pet's Date of Birth*

DayMonthYear

Sex*

MaleFemale

Species*

DogCatOther

Breed*

Color*

Pet’s current weight*

What’s the most your pet ever weighed?*

My regular vet clinic/hospital is:

How did you hear about Journey’s End services:

Reason for seeking euthanasia:

I, the undersigned, being over 18 years of age, am the legal owner or legally authorized agent for the owner, of the animal described above. If I am not the owner, then I am requesting euthanasia with the full knowledge and consent of the owner. I am declining further medical care for the above animal, and requesting euthanasia.

I authorize Dr. Sharon Sernik, and Journey’s End Home Euthanasia Service Inc. to perform this euthanasia, and release them from any and all liability for performing said euthanasia.

I agree to have Dr. Sernik choose a euthanasia protocol at her sole and exclusive discretion, and have had all of my questions and concerns regarding this process answered before signing this consent.

I certify that the animal described above has not bitten or scratched anyone in the last 15 days, or been exposed to rabies.

I understand that euthanasia involves administering injections, which will cause painless and irreversible death.

For aftercare of my pet’s body, I have chosen:*

Handling aftercare myself (home burial, taking to my vet, taking to crematory, etc.)Communal CremationPrivate Cremation (ashes returned)

For Private Cremation:*

Return my pet to me UPS signature required (Final Gift charges $25 for this.and someone must be there to sign)I would prefer to pick up my pet from Dr. Sernik in Merrimack, NH

Shipping address:*

($25 shipping fee added for UPS shipping)

Please choose one of the urns below. Any of these are included in the price of the private cremation:

Today's Date*

Signature*