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.*

Yes, one or more of the conditions listed above applies to me or my household.No, none of the conditions listed above apply to me or my household.

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.

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?*

YesNo

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 agree

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.*

YesNo

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:*

Return remains to me for personal dispositionCremation without ashes returned to mePrivate cremation with ashes returned to me (includes 1 paw print)

*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)*

I agree

Select urn option for Private Cremation*

Optional selections

Pawprint ($35 for each additional)Etching for Urn (additional cost)

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?*

YesNo

Please list what belongings are at our hospital*

What would you like to do with the belongings?*

Take homeDonatePick up with remains

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