Euthanasia Consent – Chester Valley Veterinary Hospital

Owner's Name *

First

Last

Owner's Email *

Owner's Main Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Pet's Name

Pet's Breed

Pet's Sex

Male
Female

Fixed *

Yes
No

Pet's Age/Date of Birth

Pet's Weight

Pet's Color

I am the owner (or authorized agent of the owner) of the animal described above. I hereby order and give Chester Valley Veterinary Hospital and its personnel complete authority to euthanize my pet in whatever humane manner they deem appropriate, and to dispose of its remains as specified below and in accordance with hospital policy. I hereby forever release Chester Valley Veterinary Hospital and its personnel from any liability that may arise from euthanizing or disposing of my pet. *

I have read and agree

To the best of my knowledge my pet has not bitten any person or animal during the past ten (10) days, nor has my pet ever been exposed to rabies. *

My pet has not bitten anyone.
My pet has bitten someone.

I hereby grant permission for a postmortem study of my pet, if deemed necessary by the veterinarian. I request that my pet’s remains be cared for as follows: *

Private cremation with the ashes returned *includes paw print
Communal cremation without return of the ashes
Return of the pet’s body to me for home burial (subject to applicable law)

Would you like a Paw Print to memorialize your pet? *

Yes
No

(Private cremation includes a paw print)

Please indicate desired quantity of pawprints

(Additional charges apply for each additional pawprint)

If your pet has a collar, bed, blanket, or a kennel etc... would you like to have it donated or returned to you? *

Returned
Donated

I have carefully read, and fully understand, this consent. The fees associated with these services have been explained to me, and I agree to pay such fees in full at the time of service. *

I have read and understand

Signature *

Today's Date *

Euthanasia Consent Form