Euthanasia Consent Form | Rockwall Urgent Vet

Name*

First Last

Email*

Phone*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Care Veterinarian*

Pet Name*

Pet Species

Pet Color/Markings

Pet Sex

Breed

Pet Age (Yrs)

I hereby certify that I am the owner of this pet. I request humane euthanasia of the above animal and release the staff of Rockwall Urgent Vet from all liability associated with performing the procedure.*

Yes
No

Rabies testing is mandatory by the state of Texas if a bite is reported. Please choose one of the following statements:*

To the best of my knowledge, this animal has NOT bitten any person in the previous 10 days and has not been exposed to rabies.
A bite HAS occurred in the previous 10 days. I understand that additional fees will apply for mandatory state testing and the department of health will be notified.

I request the following after-care*

Private cremation with return of ashes ($205)
Communal cremation with NO return of ashes ($90)
Home burial (burial bag provided for transport)

Please Select Memorial Options Below*

Paw Impression ($15)
Hair Lock (Complimentary)
None

Memorial items & cremated remains will be held for no more than 15 days from the time of euthanasia. Rockwall Urgent Vet reserves the right to dispose of said items if they are not picked up within this time frame. Every effort will be made to communicate when these items are ready.*

I acknowledge & understand the above statement

Signature*

Comments

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