Serene Passages Euthanasia Consent

Serene Passages Euthanasia Consent

We are so sorry you are facing this difficult decision. Please fill in the following consent form prior to our visit.
First Name*
Last Name*
Phone Number*
Please enter a valid phone number.
Additional Phone Number
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have a separate mailing address?*

YesNo
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pet's Information
Pet's Name*
Species*

DogCat
Breed*
Color
Sex*

MaleFemaleNeutered MaleSpayed Female
Weight*
Age*
To ensure we’re providing compassionate, ethical care, we require medical records with a confirmed diagnosis for any pet under the age of 8 before scheduling an appointment.

We’re also unable to assist with euthanasia for behavioral concerns or aggression.

If you’re unsure whether your pet qualifies or need help obtaining records, please reach out — our Care Team is here to support you.
Pet's Medical Records

Cancelof
Please list any veterinarian offices you would like us notify of your pet's passing after your appointment:

Consent
Euthanasia Authorization
I certify that I am the legal owner, or the authorized agent of the owner, of the pet described above. I give Serene Passages, and its veterinarians, staff, authorized agents and representatives full and complete permission to perform humane euthanasia and handle aftercare as I have indicated. I release Serene Passages and its team from all liability related to this procedure and aftercare.*

I have read and agree.
Rabies Statement
To the best of my knowledge, my pet has not bitten, scratched, or otherwise potentially exposed any person or animal to rabies in the past 10 days. I understand that if such an incident has occurred, I will notify Serene Passages staff and a rabies test is required. This will incur additional fees which I am responsible for.*

I have read and agree.
Acknowledgment of Procedure
I understand that euthanasia is the act of ending a pet’s life in a peaceful, painless way to prevent further suffering. I confirm the information I’ve provided is complete and accurate. I understand the procedure may be performed immediately upon signing this consent.*

I have read and agree.
Cancellation & Deposit Policy
I have read the Cancellation & Deposit Policy and agree to the following:*

Appointments booked more than 24 hours in advance – Cancellations made with more than 6 hours’ notice will receive a full refund. Cancellations with less than 6 hours’ notice will incur a $150 late cancellation fee, which must be paid within 24 hours. If payment was made in advance, the fee will be deducted from your refund.Same-day appointments – A $150 non-refundable deposit is collected at the time of booking. This deposit will be applied toward your appointment cost if kept. If you cancel, the deposit will not be refunded.
Payment Policy
Fees for services have been explained to me, and I accept full responsibility for all charges. Payment in full is due at the time of service. Payment will be considered late 7 days after the appointment has been completed and a 10% late fee will be added monthly to the total for delinquent payments.*

I have read and agree.
Owner/Agent Signature*

Clear
Date *

MonthDayYear
Date
Is the above signature from an Owner or Agent?*

OwnerAgent
Witness Signature*

Clear
Date *

MonthDayYear
Date
Should be Empty:

Serene Passages Euthanasia Consent

Pet's Information

Aftercare Arrangement Options

Consent