Euthanasia Consent Form

Full Name

Phone Number

Home Address

City

Zip Code

Email Address

Pet's Name

Species

Breed

Sex

Date of Birth/Age

Color

Weight (lbs)

Previous Veterinary Clinic

Please let us know your wishes for aftercare:

Private Cremation (ashes will be returned to you)

Communal Cremation (ashes will NOT be returned to you)

I wish to handle and take full responsibility for all aftercare arrangements personally. I am aware of any applicable laws and regulations regarding the burial of a pet’s body.

I certify that I am the legal owner or authorized agent for the owner of the animal described above and hereby give Bell Mobile Veterinary Care full and complete authority to euthanize and arrange cremation services for said animal in a humane manner. I hereby forever release and hold harmless Bell Mobile Veterinary Care and any authorized agents, staff, or representatives from any and all liability for euthanasia and disposal of said animal. To the best of my knowledge, my pet 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 understand that euthanasia is the act of ending the life of an animal in a painless way to prevent any unnecessary suffering. To the best of my knowledge, the information I have provided is accurate and complete. Fees for these 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 this agreement.

I understand that Dr. Bell may perform a physical exam on my pet upon arrival at my home and reserves the right to decline euthanasia services based on her medical assesment

Date

Owner/Authorized Agent Signature

Thank you for your submission.