Euthanasia Consent – Segura Veterinary Hospice

Date

How did you hear about us?

Owner Information
All marked fields (*) are required.

First Name

Last Name

Address

City

Postal Code

Phone

Regular Vet Clinic *

Pet Information

Pet's Name

Species *

Gender

Age (Years)

Weight

Color

Breed

When was the date of your last visit to a vet clinic? *

At which clinic was your visit? *

What diagnosis was given or what is your pets current issue? *

How long has your pet had this issue? *

List the medication your pet is taking

Has your pet bitten or scratched someone in the last 10 days? *

Yes

If so, please provide details:

Please choose one of the following:

Individual Cremation Communal Cremation Burial at Home

Individual Cremation
I wish to have my pet cremated and I would LIKE the ashes returned to me, I have been quoted for this service and understand that it is ADDITIONAL to the cost of the euthanasia.

Communal Cremation:
I wish to have my pet cremated and I would NOT LIKE the ashes returned to me, I have been quoted for this service and understand that it is ADDITIONAL to the cost of the euthanasia

If you’re choosing individual cremation please list the vet clinic where you would like the ashes to be returned?

Disclaimer

By submitting this form:

I hereby certify that I am the legal and rightful owner of the pet mentioned above.

I authorize Dr. Maria Segura and all veterinarians, agents, staff, and representatives therein to euthanize and dispose of mentioned animal.

I recognize that if the animal has scratched or bitten anyone in the last ten days, it may have to be tested for rabies by local authorities after euthanasia.

I release and hold harmless all agents, staff, and representatives from any liabilities that may arise from the euthanasia and disposal.

I understand that the euthanasia process is used to painlessly put an animal down and have read the information provided on the subject.