In-Home Euthanasia Consent Form

In-Home Euthanasia Consent Form

Please review and complete this form to provide your informed consent for the in-home euthanasia procedure.
Owner's Full Name*

First NameLast Name
Owner's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Owner's Email Address*
example@example.com
Owner's Address Where Euthanasia Will Take Place*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Pet's Name*
Pet's Breed*
Pet's Species*
Pet's Age*
Reason for Euthanasia*
I understand that euthanasia is the humane termination of life. I request and authorize Inland Northwest Veterinary Services to perform euthanasia on my pet. I acknowledge: • The nature and purpose of the procedure have been explained to me. • While euthanasia is designed to be peaceful and painless, involuntary movements, muscle tremors, vocalization, agonal breaths, loss of bladder/bowel control, or other reflexive actions may occur and are normal physiological responses. • Sedation may be administered prior to euthanasia. • I may choose to be present or not present during the procedure.
Owner's Signature*

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