Euthanasia Consent Form

Patient Information:

Pet's Name:(Required)

Species:(Required)

Breed:(Required)

Color/Markings:(Required)

Date of Birth:

Owner's Name:(Required)

First Last

Phone Number:(Required)

Address:(Required)

Procedure Information:

Reason for Euthanasia:(Required)

Date and Time of Euthanasia:

Date

Time

Location (if different from the home address):

Discussion of Euthanasia:

I, the undersigned owner or authorized agent, have discussed the decision for euthanasia with the veterinarian at Symphony Mobile Veterinary Clinic and give them permission to euthanize and dispose of said animal in whatever humane manner the veterinarians of Symphony Mobile Veterinary Clinic, their agents, staff, servants and representatives deem appropriate. I also release the veterinarians at Symphony Mobile Veterinary Clinic, their agents, staff, servants and representatives from any and all liability for so euthanizing and disposing of said animal. I understand that euthanasia is a humane method of ending my pet's life, and it has been recommended based on considerations of the pet's health, quality of life, and any existing medical conditions.

Consent for Euthanasia:

I voluntarily and with full understanding, consent to the euthanasia of my pet. I understand that the procedure involves the administration of medications that will peacefully and painlessly end my pet's life, including an injection of a sedative medication prior to the euthanasia solution.

I do also certify that to the best of my knowledge the said animal has not bitten any person/animal or been exposed to rabies virus in the last ten (10) days.

Aftercare Options: I have been informed of the available aftercare options for my pet's remains. (Please select one):(Required)

Individual Cremation with the return of ashes

Group Cremation (ashes will not be returned)

Home Burial (if permitted by local regulations)

Witness to Euthanasia: I understand that I have the option to be present during the euthanasia procedure. (Please indicate your choice):(Required)

I wish to be present

I do not wish to be present

Memorial Keepsakes: I am aware that Symphony Mobile Veterinary Clinic offers memorial keepsakes or services (clay paw print) as a remembrance of my pet. (Please indicate your interest or non-interest):(Required)

I would like a clay paw print (1 free gift per family)

I would like an additional clay paw print ($15 each)

I am not interested in memorial keepsakes

Financial Responsibility:

I understand that I am financially responsible for all charges associated with the euthanasia procedure and any selected aftercare option. An estimate of charges has been provided per my request, and I agree to make payment in full at the time of service. I understand that there will be no refunds or exchanges of any kind. If payment is not received at the end of the visit, payment is canceled, card is declined, card charges are disputed, or if a check is returned I will be charged a $500 late/no payment fee that will be added to my current bill.

Emergency Care Authorization:

In the event of any unexpected complication during the euthanasia procedure, I authorize Symphony Mobile Veterinary Clinic to provide any necessary and reasonable medical care in the assistance of my pet’s passing.

Owner's Signature:(Required)

Date:(Required)

Veterinarian's Signature:

Date:

Thank you for entrusting Symphony Mobile Veterinary Clinic with the difficult decision of euthanizing your pet. If you have any further questions or concerns, please feel free to discuss them with the veterinarian before signing this consent form.

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