Euthanasia Authorization Form Carlson

We thank you for helping us give you the best service possible by completing this
form within 24 hours of receiving.

I, the undersigned, hereby certify that I am the owner or duly authorized agent for the owner of the animal described below. I consent to, and order, euthanasia to be performed on that animal. I further authorize the attending veterinarian, his agents, and representative’s full and complete authority to dispose of said animal according to the laws of the State of Illinois regulating pathological disposal through Hinsdale Animal Cemetery.

I realize the attending veterinarian must pay a fee for the disposal of said animal, and do hereby and by these presents forever release the said Doctor, his agents, and representative’s from any and all liability for the performance of the euthanasia and disposal of the said animal. To the best of my knowledge and belief this animal has not been exposed to Rabies and I do also certify the said animal has not bitten any person or animal during the last fifteen (15) days preceding this date and to the best of my knowledge has not been exposed to Rabies.

We can also refer you, the pet owner, to the cemeteries for other available options.

Please select your cremation option preference below:

COMMUNAL CREMATION: Refers to deceased companion animal, which are placed in the incinerator with no attempt to prevent commingling of the ashes of different animal such that specific remains cannot be attributed to an individual animal. Owners will not receive any ashes for their keeping. INDIVIDUALLY PARTITIONED CREMATION: Each deceased companion animal is cremated in the incinerator individually, and in which the ashes of the animal are prevented from commingling with the ashes of other animals. The ashes are returned to the pet owner in an urn chosen by you, the pet owner.

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If you would like a necropsy performed on your pet, please indicate by signing below:

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CANCELATION POLICY

While we do understand emergencies and other scheduling conflicts can happen and are sometimes unavoidable, we request a 24-hour notice to change or cancel an appointment. After two missed or canceled appointments without the appropriate 24-hour notice, Carlson Animal Hospital will apply a $50.00 cancellation fee.

Thank you for completing this questionnaire. If you have any questions please call us 708.383.3606