Authority for Euthanasia

Name:: First Name:
Last Name:
Email:
Phone:
Address:: Line 1:
Line 2:
City:
Country:
State:
Postal Code:
Date of Euthanasia:
: (If this hasn’t been decided yet, please leave blank and we will contact you to arrange.)
I am:: OwnerAuthorised Agent
: of the animal described below, am above 18 years of age, and I consent to the euthanasia of this animal by a veterinarian at this practice.
Pet's Name:
Species:
Breed:
Colour:
Sex:: MaleFemale
Age:
Date of Birth:
Microchip Number:
Aftercare
Please select the option that describes your wishes::: I agree to allow the practice to keep my pet’s body after euthanasia.I wish my pet’s body to be returned to me/owner.I request cremation but do not want the ashes returned to me/owner.I request cremation and the ashes returned to me/owner.