Client Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Alternate Phone Number

Email *

Pet's Name *

Type of Pet *

Sex *

Breed *

Color *

Age/Date of Birth

Chip Number

AUTHORIZATION *

I, the undersigned, certify that I am the owner (or authorized agent of the owner) of the animal described above. I request, consent to, and order euthanasia to be performed on the described animal.
I, the undersigned, give Dr. Whitehouse (and her agents and representatives) full and complete authority to euthanize and cremate said animal in a humane manner and in accordance with the rules and regulations of this establishment. Furthermore, I release the veterinarian, representatives and clinic from any and all liability of this euthanasia.
I understand that euthanasia is the act of ending the life of an animal in a painless way to prevent any unnecessary suffering.

Signature *

Signature Date *

Euthanasia Consent Form

Ready For A Visit?