Euthanasia Form

Euthanasia Request and Consent Form
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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.Format: (000) 000-0000.
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
If this Animal is Insured:

The Insurance Company has been notified as of:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year8/27/2025
Insurance Company Name

NamePhone Number
Should be Empty:

Euthanasia Request and Consent Form