400037 - Marine View Veterinary Hospital - Euthanasia Authorization Form

Please let us know if you or anyone in your household has been sick with respiratory symptoms or fever, is potentially positive for COVID-19, or is under quarantine orders from a doctor, so that we can take appropriate precautions.

Printed Name for E-Signature for COVID-19 Status

First NameLast Name

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Where are you parked (spot #)?

Pet's Name

Age

Species

List Species Type:

Sex

Breed

Color

Weight

Reason for Euthanasia

Would you like to be present for your pet's euthanasia?

We are able to accommodate and provide social distancing for safety. If you choose not to be present, one of our staff will be present on your behalf.

Regular Veterinarian

I, the undersigned, do hereby certify that I am the owner or agent for the animal described above, that I am 18 years of age or older, and that I give the doctors of Diamond Veterinary Hospital permission to humanely euthanize the pet named above. I also release the doctors, their agents, servants and representatives from any and all liability for so euthanizing of said animal.

I certify that to the best of my knowledge, the pet described above has not bitten any person or animal during the last ten (10) days and has not been exposed to rabies.

It is my desire to provide humane after-care for my deceased pet that complies with all state, provincial, and local laws. I have been informed of all my options for disposition of the body and hereby authorize the attending veterinarian to dispose of the remains in accordance with hospital policy and via the option I have selected below:

*Ashes that are not picked up within 3 months of the euthanasia date will be returned to the cremation company for respectful disposal.

I agree to comply with local, state, and federal laws/ordinances/EPA regulations for pet burial. See link: https://snohomishcd.org/sound-farms-resources/2016/3/17/after-an (WAC 16-25-025)

Select urn option for Private Cremation

Optional selections

Quantity of pawprints?

Please write out etching requested

We will confirm with you prior to final etchings

Does the pet have any belongings at our hospital?

Please list what belongings are at our hospital

What would you like to do with the belongings?

Our crematory service is unable to cremate any items with your pet's remains, with the exception of flowers/plants.

Printed Name for E-Signature

First NameLast Name

Date

MonthDayYear

Are you a robot?

Euthanasia Authorization

COVID-19 Message

Client Information

Pet Information

Agreement