Vetcierge NJ Euthanasia Consent Form

Vetcierge Euthanasia Consent Form
Owner's Name(s)*

First name(s)Last name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Pet's Name*
Species and Breed*
Age
Approx Weight*
Sex

MF
Spayed/Neutered?

YesNo
Reason for euthanasia (optional)
Primary veterinary hospital(s)
How did you hear about us?
Aftercare Request

Private cremation (return of your pet's ashes)Communal cremationI will arrange my own aftercare service.
Preferred delivery of remains

I will pick them up at Final Gift in Clifton, NJShipped via UPS or personally delivered ($30)
Clay Paw Print Keepsake (First clay paw is no charge with private cremation, additional are $30)

Yes
Additional Clay Paw Prints ($30 Each)
Ink Prints ($15 each)

Ink Paw PrintInk Nose PrintPlease note quantity or other notes below
--I certify that I am the owner or authorized agent of the owner, for the above named animal and hereby give a Vetcierge and it's Doctors full and complete authority to perform euthanasia of my pet. Arrangements for aftercare will be based on the wishes of the owner/agent and documented above.

--To the best of my knowledge, the information I have provided on this form is accurate. I do certify that this animal has not bitten any human or other animal within the last 10 days.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Vetcierge Euthanasia Consent Form