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

Euthanasia Consent Form - New Patient

Answers to the following questions are important to ensure a smooth process during a difficult time or situation.

Owners First and Last Names*
First Last
Physical Address*
Street Address Address Line 2 City State ZIP Code
Mailing Address (if different)
Street Address Address Line 2 City State ZIP Code
Mobile Phone Number*
Your animal's name?*
Your animal's age?*
Sex*
- Male
- Male Neutered
- Female
- Female Spayed
Your animal's species?*
- Horse
- Dog
- Cat
- Other
Your animal's breed?*
Your animal's approximate weight?*
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*
Date Format: MM slash DD slash YYYY
Signature*
Sign with finger if mobile phone or tablet, drag mouse if PC or Mac.
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

Euthanasia Consent Form – New Patient

Euthanasia Consent Form - New Patient