Euthanasia Consent Form Cheyenne

Owner's Name *

First Name Last Name

Pet's Name *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Please enter a valid phone number.

Pet's Age *

Gender *

Breed *

Color of Coat *

Email

example@example.com

I, the undersigned, certify that I am the owner or authorized agent for the owner of the above described animal and I have the authority to execute this consent. I also certify that the animal has not bitten a person or animal in the past 10 days.

On this date, I do hereby give the doctors of Cheyenne West Animal Hospital complete authority to perform euthenasia of this animal, provide for final disposition of the remains, and I release them from any and all liability. I further understand that I assume financial responsibility for all services rendered.

I request the final disposition of my pet's remains to be the following: *

I will take my pet's remains for burial. I request my pet's remains to be cremated and the ashes returned to me. I will contact a pet cemetery to make the appropriate arrangements. I request my pet's remains to be cremated, but ashes will NOT be returned to me. I authorize the hospital to take care of my pet's remains in accordance with hospital policy. I give permission for postmortem examination of my pet (additional charges may apply).

Signature

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