Euthanasia Consent Form

Owner/Agent Name

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

- Area Code Phone Number

Email

example@example.com

Pet's Name

Species

Breed

Color

Age in years

Weight in lbs

Sex

Male Female

Spayed/Neutered/Gelded

Yes No

Were you referred to us by a Veterinary Clinic ?

Please provide the name of any other veterinarians who have seen your pet in the last 3 years ?

After Care Arrangements

I will handle and take full responsibility for all after care arrangements myself. I am aware of any applicable laws and regulations regarding the burial of my companion animal's body and understand caution should be taken when disposing of animals euthanized with drugs/chemicals.

Yes

I certify I am the legal owner or duly authorized agent for the owner of the animal described above and give 5 Elements for Animals Holistic Veterinary House Calls and any authorized agents, staff, or representatives full and complete authority to euthanize and dispose of my animal in an humane manner. I forever release and hold harmless 5 Elements for Animals Holistic Veterinary House Calls and any authorized agents, staff, or representatives from any and all liability for euthanasia and disposal of my animal.

Yes

Dogs, Cats and Ferrets: To the best of my knowledge, the dog, cat or ferret described above has not bitten, scratched and/or potentially exposed any person or other animal to rabies in the past ten (10) days. Other Species: To the best of my knowledge, the animal described above has not bitten, scratched and/or potentially exposed any person or other animal to rabies in the past thirty (30) days.I understand that if the animal described above has bitten or otherwise potentially exposed any person within the time specified, a rabies test must be performed.

No rabies exposure

I understand euthanasia is the act of ending the life of an animal in a painless way to prevent unnecessary suffering. To the best of my knowledge, the information I have provided is accurate and complete. I understand my wishes may be carried out immediately upon my signing this agreement. Fees for these services have been explained to me, and I assume full responsibility for all charges applicable to such services.

Yes I have carefully read and fully understand the foregoing provisions.

Signature

Clear

Date