Euthanasia Authorization

Client Name:

Address:

Phone Number:

Patient Name:

Species:

Breed:

Sex:

Color:

Birthday:

Weight:

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 Bon Air Animal Hospital permission to euthanize and dispose of said animal in whatever humane manner the doctors of Bon Air Animal Hospital, their agents, servants or representatives deem appropriate. I also release the doctors, Bon Air Animal Hospital, their agents, servants and representative from any and all liability for so euthanizing and disposing of said animal.

I do also certify, that to the best of my knowledge, said animal has not bitten any person or animal during the last fifteen (15) days, and has not been exposed to rabies.

Disposition of remains:

Private Cremation - Ashes returned

Metal Standard Urn Blue

Rosewood Box

Fur Clipping

Clay Paw Print with Name in Faux Leather Case - $46.10

Ink Paw Print - $21.50

Ink Noseprint - $21.50

Pet's Name spelled:

Date Engraved:

Yes

Dates:

Untitled checkboxes field

Communal Cremation - No ashes returned

Client to take remains

Client Signature:

Signature