Owner's Name *

First

Last

Second Contact (Authorized for pet’s healthcare decisions) *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

County *

Email *

Primary Phone *

Secondary Phone

Date of Appointment *

Pet's Name *

Species *

Dog
Cat

Sex *

Male
Female

Spayed/Neutered? *

Yes
No

Age/Date of Birth (if known) *

Breed *

Color

Additional comments or concerns

Euthanasia Fee – $135 up to 50 lbs (add $10 per 10 lbs)

After Care Arrangement Options:

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 Animal Works Veterinary Surgery arrange for my pet’s aftercare (please select one of the following).

I wish to have Animal Works Veterinary Surgery arrange for my pet’s aftercare:

Private Cremation (only the remains of your pet in urn of choice, $165 up to 50 lbs. (add $10 per 10 lbs.) (this service is in addition to the euthanasia fee)
Communal Cremation (no ashes returned and cremated with other pets, $75 up to 50 lbs. (add $10 per 10 lbs.) (this service is in addition to the euthanasia fee)
Paw Print (personalized, custom-made clay print of your pet’s paw)

I certify that I am the legal owner or authorized agent for the owner of the animal described above and do herby give Animal Works Veterinary Surgery and any staff, veterinarians, authorized agents, or representatives full and complete authority to euthanize and dispose of said animal in a humane manner. I hereby forever release and hold harmless Animal Works Veterinary Surgery and any staff, veterinarians, authorized agents, or representatives from all liability for euthanasia and disposal of said animal. *

I have read and understand

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 ten (10) 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/alleviate unnecessary suffering. To the best of my knowledge, the information I have provided is accurate and complete. Fees for the 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

I agree that a digitally scanned or photographic copy of this authorization and instruction shall be as valid as the original. *

I have read and understand

Owner / Authorized Agent's Signature *

Date *

Euthanasia Authorization Form

Please complete this form before your visit.

Author

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