Owner's/Agent's Name *

First

Last

Date *

Address *

Address Line 1

City

State

Zip Code

Phone *

Additional Phone

Email *

Pet's Name *

Species *

Dog
Cat
Other

If other, please specify *

Breed *

Age/Date of Birth *

Weight *

Sex *

Male
Male (neutered)
Female
Female (spayed)

Please list any health concerns for your pet. *

How did you hear about our services? *

Please list all veterinarians and pet care professionals who have seen your pet within the last 3 years:

After Care Arrangement Options

Please select an arrangement *

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 a pet’s body and understand caution should be taken when disposing of animals euthanized with drugs/chemicals.
I wish to have Caring Heart Veterinary Services arrange for my pet's aftercare (you must select one of the options seen below):
I wish to have a separate cremation service arrange for my pet's aftercare.

I wish to have Caring Heart Veterinary Services arrange for my pet's aftercare (you must select one of the following): *

Communal cremation (no ashes returned)
Private cremation with ashes returned to me

I certify that I am the legal owner/duly authorized agent for the owner of the animal described above, and do hereby give Dr. Allegra Liu, Caring Heart Veterinary Services, and any authorized agents, staff, or representatives full and complete authority to euthanize and handle aftercare of said animal in a humane manner. I hereby forever release and hold harmless Dr. Allegra Liu, Caring Heart Veterinary Services, and any authorized agents, staff, or representatives from any and all liability for euthanasia and disposal of said animal. *

I have read and understand

Dogs, Cats and Ferrets: To the best of my knowledge, the dog, cat, or ferret described above has not bitten, scratched, or otherwise 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, or otherwise 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. *

I have read and understand

I understand that euthanasia is the act of ending the life of an animal in a painless way to prevent any unnecessary suffering. To the best of my knowledge, the information I have provided is accurate and complete. I understand that 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. I have carefully read and fully understand the foregoing provisions. *

I have read and understand

Signature of responsible party *

Clear Signature

Date *

Is the above signature Owner or Agent? *

Owner
Agent

Witness signature *

Clear Signature

Date *

Euthanasia Consent Form

Please complete this form before your visit.

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