Euthanasia Release Form

Name

Address

City

State

Zip

Phone

Email

Pet's Name

MaleFemale

FelineCanine

Pet Age

Pet Weight (lbs)

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 $600

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

Name (print please)

Date