Client Intake Form

Patient Information
Pet's Name
Species
Breed
Any aggression exhibited by pet that may necessitate a muzzle during visit?
Sex
Color
Age
Approximate Weight
in lbs.
Primary Veterinarian or Clinic
Primary Veterinarian or Clinic Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Please provide a brief summary discussing why your pet is a candidate for euthanasia:

Euthanasia Consent Form

QUESTIONS REGARDING ANY OF THE REQUIRED STATEMENTS BELOW CAN BE ADDRESSED BY THE ATTENDING DOCTOR.
I, the undersigned, certify that I am the owner (or an authorized agent for the owner) of the animal described above and I consent to, and order euthanasia to be performed on said animal.
I have read and understand the above statement
I do hereby give the doctors of Compassionate Crossings of Birmingham, LLC, their
staff, and representatives full and complete authority to euthanize and handle the
aftercare of said animal. Furthermore, I forever release the said doctors of Compassionate Crossings of Birmingham, LLC, their staff, and representatives from all liability for euthanizing and aftercare of said animal.
I have read and understand the above statement
To the best of my knowledge, said animal has not bitten any person or animal during the last ten (10) days and has not been exposed to rabies.
I have read and understand the above statement
I understand that I assume all financial responsibility for all services rendered. Due to the nature of the services and products offered, all sales are final.
I have read and understand the above statement
Signature
Date

MonthDayYear
Date

Compassionate Crossings, LLC