Euthanasia Authorization Form Client Name* First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email* Owner DOB Date Format: MM slash DD slash YYYY Patient Name*Patient InfoSpeciesBreedSexColorDOB I the undersigned, do hereby certify that I am the owner or duly authorized agent for the owner of the animal described above, that I do hereby give the doctors of Emergency Pet Hospital of Redlands permission to euthanize and dispose of said animal in whatever humane manner the doctors of Emergency Pet Hospital of Redlands, their agents, servants or representatives deem appropriate. I also release the doctors, Emergency Pet Hospital of Redlands, their agents, servants and representative from any and all liability for so euthanizing and disposing of said animal. I do also certify that to the best of my knowledge the said animal has not bitten any person or animal during the last fifteen (15) days and has not been exposed to rabies.PLEASE INDICATE YOUR DECISION FOR CARE OF REMAINS BY INITIALING BELOW*Private cremation- remains will be picked up by Gateway Pet Cemetery and returned to the clinic for pickup by owner unless otherwise specified.EPHR paw print ONLY with Communal cremation.Communal cremation.Owner to take remains home.Owner to take remains home with EPHR paw print.Please hold remains pending our decision. If I have not informed the clinic of our decision within 10 days, I authorize communal cremation.**Name should appear on urn:Learning the cause of death of your pet can be of great help in relieving the suffering of other pets, as well as contributing to our understanding of heath and disease. Unless you request otherwise, a postmortem evaluation may be performed on your pet prior to cremation. Should we choose to do this, you will not be charged unless you wish to receive a report. Postmortem Evaluation I do NOT authorize a postmortem evaluation Client Signature*Date* Date Format: MM slash DD slash YYYY CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
