Owner's/Agent's Name *

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Last

Date *

Address *

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City

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Phone *

Additional Phone

Email *

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Pet's Name *

Species *

Dog
Cat

Breed *

Age/Date of Birth *

Pet's Color *

Weight *

Sex *

Male
Male (neutered)
Female
Female (spayed)

Please list any health concerns, including aggression, for your pet. *

How did you hear about our services? *

Please list all veterinarians and pet care professionals who have seen your pet within the last 3 years:

What medications is the pet currently taking? *

Aftercare Arrangement Options

I will handle and take full responsibility for all aftercare arrangements myself. I am aware of any applicable laws and regulations regarding the burial of a pet’s body and understand caution should be taken when disposing of animals euthanized with drugs/chemicals. *

I have read and understand

I certify that I am the legal owner/duly authorized agent for the owner of the animal described above and do hereby give Dr. Victoria Benson, Sweet Rock Pet Hospice, and any authorized agents, staff, or representatives full and complete authority to euthanize said animal in a humane manner. I hereby forever release and hold harmless Dr. Victoria Benson, Sweet Rock Pet Hospice, and any authorized agents, staff, or representatives from any and all liability for euthanasia of said animal. *

I have read and understand

To the best of my knowledge, the dog, or cat described above has not bitten, scratched, or otherwise potentially exposed any person or other animal to rabies in the past ten (10) days. I understand that if the animal described above has bitten or otherwise potentially exposed any person within the time specified, a rabies test must be performed. *

I have read and understand

I understand that euthanasia is the act of ending the life of an animal in a painless way to prevent any unnecessary suffering. To the best of my knowledge, the information I have provided is accurate and complete. I understand that my wishes may be carried out immediately upon my signing this agreement. Fees for these services have been explained to me, and I assume full responsibility for all charges applicable to such services. I have carefully read and fully understand the foregoing provisions. *

I have read and understand

Signature *

Clear Signature

Date *

Is the above signature Owner or Agent? *

Owner
Agent

Euthanasia Consent Form

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We bring comforting care to your home.

Saying goodbye is never easy, but we’ll be there to ensure that you’re able to say goodbye to your pet in a safe and calm manner. We’ll be there every step of the way to ensure the final moments with your pet are full of love and dignity.

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