EUTHANASIA CONSENT FORM
Owner’s Name: ______________________________ Date: __________________
Mailing Address: _____________________________Phone: _________________
Pet’s Name: ____________________ Breed: ______________________________
Sex: ______ Age: ______ Color/Markings: _________________________________
Primary Veterinarian / Veterinary Clinic: ___________________________________
Ο As a courtesy, Cherished Pet will contact your regular veterinarian so they may update their records and extend their condolences. Please check here if you do not wish to have your primary veterinarian contacted.
Please choose an option for aftercare:
Ο Client to handle aftercare (burial or delivery or pick-up for cremation)
Ο Cremation – delivery by Cherished Pet – ashes returned
Ο Cremation – delivery by Cherished Pet – ashes NOT returned
I, the undersigned, do hereby certify that I am the owner or duly authorized agent for the owner of the animal described above, that I do hereby give Cherished Pet, Dr Brenda Smith or representative, full and complete authority to humanely euthanize my pet. I acknowledge that Dr. Smith has met with me personally and discussed the euthanasia of my animal. I also certify that to the best of my knowledge the said animal has not bitten or injured any person or animal during the last fifteen (15) days, and has not been exposed to rabies. I do hereby release Cherished Pet and Dr. Smith or representative from any and all liability for the euthanasia and disposal of the animal.
Signature of Owner or Agent:______________________________ Date: _________