Euthanasia Form

Euthanasia Request and Consent Form
Date*

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Animal Name*

Barn NameRegistered Name
BreedColor
Veterinarian*
I, the Undersigned, do hereby certify that I am the owner (duly authorized agent for the owner) of the animal described above; that I do hereby give the De Cillo Equine Clinic Veterinarian and his or her agents and representatives, full and complete authority to humanely destroy the said animal in whatever manner the said Doctor, his or her agents or representatives shall deem fit; and I do hereby and by these presents forever release the said Doctor, his or her agents or representatives from any and all liability for so destroying the said animal.
Signature*

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If this Animal is Insured:

The Insurance Company has been notified as of:
Date

MonthDayYear
8/27/2025
Insurance Company Name

NamePhone Number
Should be Empty:

Euthanasia Request and Consent Form