Euthanasia Consent Form - Established Patient - Rogue Equine & Companion Animal Clinic

Owners First and Last Names*

First Last

Mobile Phone Number*

Email Address*

Your animal's name?*

Your animal's age?*

Sex*

Male
Male Neutered
Female
Female Spayed

Your animal's species?*

Your animal's approximate weight?*

Your animal's breed?*

Has your animal bitten anyone (human or animal) in the last two weeks?*

This question must be answered due to State Regulations for possible rabies exposure.

NO
YES

Would you like to be present during the procedure?*

Due to current State regulations, this request to be present may not be possible to fulfill. Please confirm at the time of the appointment.

YES
NO

For small animals only: Cremation Options- please choose one:*

Cremation is provided at additional cost by third party. "No Return" is approximately 42.00 for any size where "Return" is 90.00 to 400.00 depending on size and choice of standard or custom urn.

NO RETURN of ashes
RETURN of ashes in STANDARD urn
RETURN of ashes in CUSTOM urn
I will make my own arrangements
NOT APPLICABLE

For horses only: Please choose one:*

Third party removal service is available at approximately 225.00 to 295.00 where burial is privately contracted.

I will make my own arrangments for burial or removal
I prefer Rogue Equine to make arrangements for removal
NOT APPLICABLE

Do you have any special requests?

We empathize with you on these difficult times and decisions. We will strive to make the situation as comfortable and compassionate as possible. Please share with us any special requests you may have.

Accuracy and Agreement/Consent*

I am the owner, or authorized agent for the owner, of the animal described hereon and I hereby consent to, and order euthanasia to be performed for humane reasons and in a humane manner. I further attest that the animal has not bitten anyone in then last 14 days.

I also acknowledge I am the responsible party for euthanasia fees and separate removal/burial (horses) or cremation (small animals) fees associated with this service.

I AGREE AND CONSENT

Date of agreement and consent*

Signature*

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Name

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Euthanasia Consent Form – Established Patient

Euthanasia Consent Form - Established Patient