Chimney Rock Animal Hospital

Euthanasia Authorization Form

Save time during your next appointment! Complete your required euthanasia authorization form from any device at any time before your visit.

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Online Form

Euthanasia Authorization Form

Client's Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Email *

Patient's Name *

Species *

Breed *

Sex *

Color: *

Weight *

Age: *

In regards to the remains of my pet I would like to: *

Have a private cremation performed and receive the ashes back
Have a private cremation performed without receiving the ashes, but receive a personal memento back
Have a communal creamtion performed and NOT receive the ashes back (no charge)
Receive the pet back for personal burial in a decomposable box (no charge)

*I do not hold Chimney Rock Animal Hospital responsible for the knowledge of whether or not this is allowed by my local municipal ordinance

I the undersigned, do hereby certify that I am the owner or duly authorized agent for the owner of the animal described above, that I do hereby give the doctors of Chimney Rock Animal Hospital permission to humanely euthanize said animal in whatever humane manner the doctors of Chimney Rock Animal Hospital, their agents, servants or representatives deem appropriate. I also release the doctors, Chimney Rock Animal Hospital, their agents, servants and representative from any and all liability for so euthanizing said animal. I do also certify that to the best of my knowledge the said animal has not bitten any person or animal duringthe last fifteen (15) days and has not been exposed to rabies. *

Clear Signature

Date *

Phone

Chimney Rock Animal Hospital

Euthanasia Authorization Form

Online Form

Euthanasia Authorization Form

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