Euthanasia Authorization Form Euthanasia Authorization Form Client's Name * Client's Name First First Last Last Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Phone * Email * Patient Name * Species * Breed * Sex * Primary Color * I certify that to the best of my knowledge the said animal has not bitten any person or animal within the last ten (10) days. * Yes No My pet has bitten a person and/or animal during the last ten (10) days. Rabies testing is required by law and there are fees associated with this test. * Person Animal Not Applicable To the best of your knowledge, has your pet been exposed to rabies within the last ten (10) days? * Yes No Please confirm your choice of care for your pet's remains * Private Cremation- Ashes Returned Communal Cremation- No Ashes Returned Client to Take Remains Client to Make Arrangements with another Agency What telephone number would you like us to call when your pet's remains are ready to be picked up? * If making other arrangements, what agency are you using? Date of Euthanasia * Time of Euthanasia * 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 Groveport Canal Animal Hospital permission to euthanize and arrange care of said animal in a humane manner the doctors of Groveport Canal Animal Hospital, their agents, servants or representatives deem appropriate. I also release the doctors, Groveport Canal Animal Hospital, their agents, servants and representative from any and all liability for so euthanizing and disposing of said animal. * I understand and agree. By signing my signature, I understand this to be my expressed written consent for the euthanasia and aftercare choice I have selected. * signature keyboard Clear Date * COVID-19 Acknowledgement For the protection of both our team and clients, have you been exposed to COVID-19 or showing signs of COVID-19 in the last 14 days? * Yes No For the safety of our team and clients, we require a face mask to be worn when you enter our building. This mask must stay on the whole time you are in the building. Please select one of the following: * Yes, I have a face mask No, I need a face mask Captcha Submit If you are human, leave this field blank.
