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Euthanasia Consent Form
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» Euthanasia Consent Form
Today's Date:
*
Date Format: MM slash DD slash YYYY
Owner's/Legally Authorized Representative's First & Last Name:
*
First
Last
Pet's Name:
*
Pet's Approximate Age:
*
Pet's Species and Breed:
*
(Ex. Canine / Golden Retriever)
Pet's Gender:
*
Female Intact
Female Spayed
Male Intact
Male Neutered
I, the undersigned, hereby state that I am the [legal owner/legally authorized representative of the legal owner] of the above listed pet and authorized to make all medical decisions regarding this pet. I have declined any further care for the above pet and am hereby authorizing Dr. Tamie Haskin with Happier At Home Mobile Veterinary Hospital to euthanize the above listed pet. I agree to have Happier At Home Mobile Veterinary Hospital choose a euthanasia protocol at their sole and exclusive discretion (including sedation prior to euthanasia) and have had all my questions and concerns regarding this process answered prior to signing this consent. It is my desire to provide for my pet decent and humane after-death care, complying with all legal requirements of the area. I authorize Happier At Home Mobile Veterinary Hospital to take charge of my pet's remains in accordance with hospital policy, releasing the staff from any and all liability for performing said after-death care.
*
I understand and agree to the terms
I attest that the above listed pet has not been exposed to Rabies, has not bitten anyone, and has not displayed any signs of unusual attitude or aggression in the last 15 days.
*
The above statement is true in its entirety.
My pet has bitten someone within the past 15 days
My pet has been exposed to Rabies within the past 15 days
My pet has had signs of unusual attitude/aggression within the past 15 days
I request that this animal’s remains be cared for in the following manner:
*
Individual Cremation with return of ashes in an urn of your choice; I wish to have my pet individually cremated offsite.
Communal Cremation with no return of ashes; My pet’s remains will be buried at the cremation facility.
Home burial; I wish to keep my pet’s body and handle the after-care.
Urn Choices:
*
Blue Scattering Tube with Paw Prints (No name)
Decorative Metal Urn - Blue (Name engraved)
Decorative Metal Urn - Tan (Name engraved)
Serenity Photo Urn (Brass nameplate)
Hand-carved Wooden Urn (Brass nameplate)
No Urn (Blue satin pouch - no name)
I will contact Abbey Glenn directly for an urn
(Photos of the urns listed below can be found under "Individual Cremation" on the previous page)
Memorial Products:
*
Clay Paw Print
Fur Jar
Fur Keychain
Ink Paw Print ($40)
1 of each
None
Memorial Products:
*
Clay Paw Print
Fur Jar
Fur Keychain
1 of each
None
Preferred ink color for fur jar:
*
(Darker colors show up better on lighter fur and lighter colors show up better on darker fur)
Preferred color for keychain tassel:
*
Blue
Red
Yellow
Pink
Orange
Purple
White
Black
Brown
If you would like more than 1 of any product, please let us know below:
"In Memory Mondays"
*
Yes, I give my consent to post my pet's photos on Facebook
I do not wish to be involved
Each Monday, on our Facebook page, we will be sharing photos and a short story about pet(s) who have passed recently. If you would like us to share a short story and photos of your pet, please feel free to attach them below or send us a separate email to info@happierathomevet.com.
Upload Photo:
Upload Photo:
Upload Photo:
Tell us a little bit about your pet (favorite memory, funny story, etc.):
*
Phone Number:
*
By clicking the "Submit" button below, I agree that I have read and understand this authorization and hereby accept and agree to the terms of the consent for treatment.
Please click the "submit" button when the form is complete
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About Us
Our Team
Services
Wellness and Vaccinations
Preventive Services
Medical Services
Surgical Services
Anesthesia and Patient Monitoring
Exotic Pet Medicine and Surgery
End of Life Services
Pet Health
How-To Videos
Pet Food Recalls
Product Recalls
Contact Us
Online Pharmacy
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