Euthanasia Release Form

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EUTHANASIA RELEASE FORM

Please fill out the following form as thoroughly as possible before your scheduled appointment. Please note: All * fields are required. If you have any questions, please don’t hesitate to call us.

Chart Number

Owner *

Phone Number

Patient’s Name *

Species *

Breed *

Age

Sex

Male
Female

Please initial one:

*As a safety feature, communal cremations are held for seven days before being cremated.)

Please initial one:

As owner of my pet, I hereby consent to euthanasia to be preformed for humane reasons and understand I am financially responsible for all expenses incurred.

Owner/Agent Signature

Clear Signature

Date

OFFICE USE ONLY

initial safety VERIFY

BEFORE PATIENT MAY BE ADMITTED, EMPLOYEE MUST VERIFY FORM IS COMPLET; INFORMATION IS CORRECT & INITIAL THIS SIDE.

Pet’s Weight

Euthanasia Release Form

EUTHANASIA RELEASE FORM

*As a safety feature, communal cremations are held for seven days before being cremated.)

OFFICE USE ONLY

BEFORE PATIENT MAY BE ADMITTED, EMPLOYEE MUST VERIFY FORM IS COMPLET; INFORMATION IS CORRECT & INITIAL THIS SIDE.

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