Euthanasia Release Form

    Name

    Address

    City

    State

    Zip

    Phone

    Email

    Pet's Name

    MaleFemale

    FelineCanine

    Pet Age

    Pet Weight (lbs)

    *Please note that due to limited staffing, pets greater than 90 pounds may require additional assistance from household members for lifting and handling. If assistance is unable to be provided, special transportation arrangements with Fond Memories will need to be made in advance.

    I would like my regular veterinarian to be notified of my pet’s passing
    Contact Information

    I certify that I am the owner or authorized agent of the owner, for the above named animal. In being the owner/agent, I do hereby give HousePaws In-Home Veterinary Care full and complete authority to perform euthanasia services. I have understand the associated charges listed below and have initialed my choice for aftercare. I understand any changes from what is signed for below will need to be made directly through Fond Memories (crematorium) and may incur additional expense.

    Euthanasia only and I choose to retain my pet for burial; fee $325

    Euthanasia and I choose to have a communal cremation performed at Fond Memories. Housepaws will provide transportation to the crematorium and I will not have my pet’s ashes returned. A clay pawprint of my pet will be made and mailed to my home by Fond Memories; fee $450

    Euthanasia and I choose to have a private cremation. Housepaws will provide transportation of my pet to Fond Memories for private cremation, will arrange return of my pet’s ashes directly to my home. This service includes an engraved wooden urn and a clay pawprint; fee $625

    Additional Comments (please provide any important additional information so that we can best accommodate you and your beloved pets needs such as apartment floor, status of your pet, scheduling requests, etc.):

    To the best of my knowledge, the information I have provided on this form is true and correct. I do also certify that this animal has not bitten, seriously scratched, or exposed anyone to rabies in the past 10 days. I understand that my wishes will be immediately carried out upon the signing of this agreement. Fees for these services have been explained to me and will be collected at the time of service.

    Owner/Agent Signature: (Please sign below.)

    Name (print please)

    Date