Euthanasia Consent Form Euthanasia Authorization Name * Name First First Last Last Email * Phone * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Patient Name * Species * Canine Feline Bird Small Mammal Reptile Amphibian Fish Sex * Male Male/Neutered Female Female/Spayed Unsure Breed * Color * I do hereby certify that I am the owner or the duly authorized agent for the owner of the animal described above, that I do hereby give the doctors of Exotic Vet Care permission to euthanize and dispose of said animal in whatever humane manner the doctors of Exotic Vet Care, their agents, servants or representatives deem appropriate. I also release the doctors, Exotic Vet Care, their agents, servants and representative from any and all liability for so euthanizing and disposing of said animal. * Yes, I give my permission No, I don't give my permission Has this pet bitten any person or domestic animal during the last ten (10) days? * Yes (The veterinarian will discuss with you required rabies testing to be done after euthanasia.) No Has this pet been exposed to possible infection with rabies through a bite from another animal during the last ten (10) days, or is this pet currently under a rabies quarantine? * Yes (The veterinarian will discuss with you rabies testing that may need to be done after euthanasia.) No Please select one of the following for disposition of remains * Home Burial (no charge, we package your pet nicely for home burial) Medical Cremation (pets under 1 pound only, no ashes returned to you, cost $20 payable to our clinic) Country Cremation (no ashes returned to you, they are scattered in the Pet Cemetery, you pay crematory directly) Individual Cremation with ashes returned to our clinic for you to pick up Individual Cremation with ashes mailed to your home (you pay crematory directly) Signature * signature keyboard Clear Date * Captcha Submit If you are human, leave this field blank.
