FM 1488 Animal Medical Center - Euthanasia Authorization Form

Name

First NameLast Name

Email

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary phone

Enter phone numberFormat: (000) 000-0000.

Patient's name

breed

sex

color/markings

age

burial service option (please select only one option). you may call our office for prices of cremation services).

Commemorative clay paw prints will be provided for all communal and private cremation services. Additional paw prints can be made for an additional fee. Would you like additional paw print made?

If you elected additional paw prints, enter how many you would like.

During the time of the COVID-19 pandemic, FM 1488 Animal Medical Center has implemented certain safety procedures we feel necessary to protect the health of our employees and the clients we interact with. By being present for an in-clinic euthanasia, you agree to abide by the following safety measures during your pets euthanasia.

(initial) No more than 4 people may enter the building to be present with your pet.

(initial) All persons who enter the building are required to wear a facemask for the duration of their time in the building (including time in the lobby and exam room).

If you are unable to adhere to these guidelines, please ask our staff for a list of local in-home euthanasia services that are provided in our area.

Ashes and/or paw prints must be picked up within 90 days of today's date or we will dispose of the items as we see fit.

Initial here to acknowledge

I, the undersigned, do hereby certify that i am the owner (duly authorized agent for the owner) of the animal described above, and i do hereby give the doctors of Fm 1488 Animal Medical center permission to euthanize said animal. i do also certify that to the best of my knowledge the said animal has not bitten any person during the last ten (10) days andhas not been exposed to rabies.