West Side Pet Clinic - Euthanasia Form

Owner Name*

First NameLast Name

Owner Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Owner Phone Number*

Please enter a valid phone number.

Owner Email Address*

example@example.com

Pet Name*

Pet Sex*

MaleFemale

We understand that this is an emotionally difficult time for you and your family, and with that in mind, we offer some options to help make this decision as easy as possible. Please review and initial the following:

In signing this release, I authorize West Side Pet Clinic to euthanize my pet, knowing this is an irreversible procedure.*

YesNo

I understand that I have the option to be present during the procedure. I can also choose not to be present, and be assured that a gentle and kind approach will be used.*

Yes, I would like to be present.No, I would prefer not to be present.

Although euthanasia is typically a painless procedure, I realize that it may be difficult in an excited or stressed pet. A pre-euthanasia injection may be given before the procedure to keep my pet calm.*

Yes, please administer.No, do not administer.

I request that my pet's remains be cared for in the following manner:*

Private cremation with return of ashes.Cremation with no return of ashes. My pet's remains will not be returned to me.Home burial. I wish to take my pet's body home.

I certify that my pet has not bitten any person or animal within the last 10 days.*

My pet has NOT bitten a person or animal in the last 10 day.My pet HAS bitten a person or animal in the last 10 days.

I have read and understand this authorization and fees have been explained to me. Please initial below:*

Today's Date*

Date

Owner Signature*

Euthanasia Consent Form