Authorization for EuthanasiaAuthorization form Client InformationClient Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Best Phone #*Email*(to receive a copy of this form) Pet InformationPet's Name*Species*DogCatSex*MaleFemaleBreed*Color*Age*Please indicate if weeks, months or yearsMost 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 ReturnedCremated OnlyNeither: I will be responsible for remainsWould you like us to notify another Veterinarian or Clinic of your pet's passing?*YesNoPlease contact : Signature*Please type your name to certify your authorization and consent.Date*Date Signed Date Format: MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged. Submit This iframe contains the logic required to handle Ajax powered Gravity Forms.