Euthanasia Authorization

Authorization to Perform Euthanasia
Client Information
Client's Name:
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Pet Information
Pet's Name:
Breed:
Pet's Age:
Color:
Species
My pet is:
Virginia State Law requires we ask you the following: Has your pet bitten anyone during the last 10 days?
What is your request for your loved one?
Clay paw print memorial. Please enter the number of clay paw's you would like:
Please enter your pets name as you would like it to appear on the clay paw memorial:
Phone to call when the your pet and/or clay paw memorial is ready for pick-up:
Format: (000) 000-0000.
Disclaimer:

Clay paws and ashes that have not been picked up within 6 months of the date above may be lovingly interred in the clinic's memorial garden.

I, the owner/owner's agent hereby consent to, and request for humane reasons, euthanasia be performed on the pet described above.
Printed Name for E-Signature

First NameLast Name
Today's Date

MonthDayYear
Signature
Should be Empty:

Authorization to Perform Euthanasia