Consent Form

Euthanasia Consent Form

Please fill out the following form below.

Owner Information

Date

Address

Owner

Phone

Animal Information

Name of Animal

Species and breed

Veterinarian

Age of Animal

Pet's Weight

Color

Please Mark The Check Box Below If You Agree

I , the undersigned, certify that I am the owner (or an authorized agent for the owner) of the above stated animal, and I consent to, and order euthanasia to be performed on the said animal. To the best of my knowledge, and belief, this animal has not bitten any person or animals during the past fifteen days and has not been exposed to rabies. I give Dr. Long (his/her) agents, and representatives) full and complete authority to euthanize and dispose of the said animal in a humane manner and in accordance with the rules and regulations of the establishment. Furthermore, I forever release the doctor or representatives from any and all liability of the said euthanasia.

Signature of Owner

Signature of Witness

Take the body home immediately after euthanasia

Communal Cremation (Ashes NOT returned)

Private Cremation (Ashes returned in an urn)

Please hold remains pending our decision (If I have no informed of our decision within 10 days, I authorize communal cremation)

Other

Initials

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!