Euthanasia Consent Form

This form is being completed for: Pet name*
Pet sex: Male/female*
Pet species:   Dog/cat*   
Pet breed:   Breed*   
Pet color:   Color*   
Pet age:   Approximate age in years*   

Initial* I hereby consent to and request euthanasia (humane death) to be performed on this animal. I am fully aware that euthanasia is irreversible.

Please indicate your decision for care of remains, by initialing your choice (choose one)
Initial Personal disposition/home burial (remains will not be removed from your home)
-OR-
Initial   Communal cremation (you will not receive ashes back, but can choose a memorial product)
-OR-
Initial   Private cremation (you will receive ashes back, and can choose a memorial product)

I certify that   Pet name* has been in my custody and under my supervision and that, to the best of my knowledge, he/she has not bitten a person or animal within the past ten (10) days.   

I certify I am the owner or responsible agent for the animal describe above, and I have the authority to give lawful consent to the terms and conditions contained on this form. I am over 18 years of age.

Written name of Owner or Responsible Agent:   First & Last   
Phone number where Owner/Agent can be reached:   Phone number   

Date:      Month/Day/Year  

By electronically signing this consent and submitting it to Peaceful Pets Mobile Veterinary Services PLLC, you are agreeing to the terms of this consent.