Euthanasia Consent Form – Acres Animal Hospital

Client and Patient Indentification

Patient Name*

Pet Owner's Name*

First Last

Pet Owner's Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Pet Owner's Phone*

Date of your schedule appointment*

Please call to schedule an appointment before submitting any consent forms. This is not an appointment request form.

Euthanasia Consent

Euthanasia Consent*

Consent of owner or authorized agent (must be at least 18 years of age):

I, the undersigned, do hereby certify that I am the owner (or duly authorized agent for the owner) of the animal described above, that I do hereby give the doctors of Acres Animal Hospital permission to euthanize said animal. I also release the doctors, Acres Animal Hospital, their agents, and representatives for any and all liability for so euthanizing and disposing of said animal.

Rabies exposure*

I do also certify that the said animal has not bitten any person or animal during the last ten (10) days, and has not been exposed to rabies.

Name of Owner or Authorized Agent*

First Last

Today's Date*

Aftercare

Aftercare Requested*

Common Cremation (ashes buried and not returned)
Private Cremation (ashes returned in urn)
Home Burial

Private Cremation Urn Choice

If you selected private cremation above, please indicate your urn choice.

Wooden Box Name Plate Inscription

If you selected a private cremation with a wooden box, please indicate the short inscription you would like on the name plate. Default inscription is the pet's name and the year of death. Inscriptions must be short. Name plates are not available with ceramic urns.

Monday	12:00pm – 6:00pm
Tuesday	12:00pm – 6:00pm
Wednesday	12:00pm – 6:00pm
Thursday	12:00pm – 6:00pm
Friday	12:00pm – 6:00pm
Saturday	Closed
Sunday	Closed
Closed Holidays

Online Euthanasia Consent Form

Client and Patient Indentification

Euthanasia Consent

Aftercare

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