Animal and Pet Veterinary Health Care by lPowell Animal Hospital / Euthanasia Consent Form

Form - Euthanasia Consent

Name (required)
First Name (required)	Last Name (required)

Address (required)
Street Address (required)


City (required)	State/Province (required)	Zip/Postal Code (required)
,

Phone (required)
Phone Type	Phone Number (required)

Phone
Phone Type	Phone Number

E-Mail Address (required) :

Pet's Name (required)

It is my desire that: (required)
My pet euthanized and released to me for burial at home ($54.02)
My pet euthanized($54.02)and sent to Resthaven for private cremation with return of ashes (additional $143.45)
My pet euthanized ($54.02) and sent to Resthaven for disposal (additional $60.71)

Euthanasia Authorization
By submitting this form, I do hereby certify that I am the owner (or duly authorized agent for the owner) of the animal described above. I do hereby give the doctors of Powell Animal Hospital and their staff and representatives full and complete authority to euthanize said animal. I do hereby release the said doctors of Powell Animal Hospital and their staff and representatives from any and all liability for euthanizing and disposing of said animal. I also certify that to the best of my knowledge that this animal has not bitten any person or animal during the last ten (10) days and has not been exposed to rabies.

I have read the above and - (required)
I agree.
I disagree.

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