EUTHANASIA FORM

Your Contact Information

Name *

Home Phone *

Mobile Number *

Work Phone

Email *

Your Pet's Information

Pet Name *

Species *

Breed *

Sex *

Color *

Markings *

Date of Birth

I, the undersigned, do hereby certify that I am the owner (or duly authorized agent for the owner) of the animal described above. I do hereby give the doctors of Colonial Veterinary Hospital, their staff, and representatives full and complete authority to euthanize and dispose of the said animal in an appropriate manner which the representatives deem necessary.

I do hereby release Colonial Veterinary Hospital, their staff, and representatives from any and all liability for euthanizing and disposing of the 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 ten (10) days and has not been exposed to rabies.

E-Signature
Date