Authorization for EuthanasiaAuthorization form "*" indicates required fields Client InformationEmail*(Used to look up your information and send you a copy) Client Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Best Phone #*Pet InformationPet's Name* Species* Dog Cat Sex* Male Female Breed* Color* Age*Please indicate if weeks, months or years Most recent weight*Please indicate pounds (lbs)Please enter a number from 1 to 200.Authorization & ConsentI, the undersigned, certify that I am the owner, or duly authorized agent for the owner of the animal described above. I do hereby give Paws at Home Inc., its veterinarian, Kristin Spear, DVM, staff and agents complete authority to euthanize and dispose of the animal described above. I release Paws at Home Inc. its veterinarians, staff and agents from any and all liability for euthanasia of said animal. I understand that my animal will be sedated and that euthanasia involves administering an intravenous injection of sodium pentobarbital causing painless and irreversible death of the adnimal described above. I certify, to the best of my knowledge, the above described animal has not bitten any person or animal during the past 10 days and has not been exposed to rabies. I choose to have the remains* Cremated with Ashes Returned Cremated Only Neither: I will be responsible for remains Would you like us to notify another Veterinarian or Clinic of your pet's passing?* Yes No Please contact : Signature*Please type your name to certify your authorization and consent. Date*Date Signed MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
