At-home Pet Euthanasia Consent Form Today's Date Phone Number Client Full Name Street Address City Zip Code Email Regular Vet Clinic Pet Name Species Breed Color Gender Male Female Altered? Spayed or Neutered Not Altered Age Weight (lbs) How would you prefer your pet's body cared for? Owner Keeping pet to perform proper disposal (+$0) Communal Cremation / No Ashes Saved (+$22-$205 depending on size 0-190lbs) Individual Partitioned Cremation / Ashes Saved (+$84-$340 depending on size 0-190lbs) Ashes Container (Included With Cremation) N/A Tin (Paw Print) Tin (Meadow) Tin (Rainbow) Wood Scatter Tube Clay Pawprint (+$27) Yes No Ink Print (+$17) Yes No Fur Clippings (+$2) Yes No Custom Urn (+$35-$90+ depending on size 0-160lbs) Yes No Nameplate (+$15) Yes No Witness The Cremation (+$85) Yes No Ruminant Animal (+$85) Yes No Consent If you would like to schedule an in home euthanasia service, please call us so we may obtain all your information and your pet information. There is a $50.00 deposit required to set appointments. This fee is non-refundable and is charged if there is a change or cancellation for any reason. If a cancellation within 2hrs of my appointment, the cancellation fee is $150. I certify that I am the [ legal owner / duly authorized agent for the owner] of the animal described above and do hereby give assigned veterinarian and technician/assistant of Peaceful Partings and any authorized agents, staff, or representatives full and complete authority to euthanize and dispose via cremation services of Peaceful Memorials Pet Crematory, of said animal in a humane manner. If cremation is agreed upon, disposition of the body by Peaceful Memorials Pet Crematory of said animal is left to the judgment of the veterinarian. I hereby forever release assigned veterinarian and technician/assistant of Peaceful Partings and any authorized agents, staff, or representatives from any and all liability for euthanasia and disposal of said animal. Cautions should be taken by owner when disposing of animals euthanized with drugs/chemicals. To the best of my knowledge, the said pet described above has not bitten, scratched, or otherwise potentially exposed any person or other animal to rabies in the past ten (10) days. Other Species: To the best of my knowledge, the animal described above has not bitten, scratched, or otherwise potentially exposed any person or other animal to rabies in the past thirty (30) days. I understand that if the animal described above has bitten or otherwise potentially exposed any person within the time specified, a rabies test must be performed. Initials Mortality Insurance If the animal described above is insured under a mortality insurance policy or any other type of insurance policy, the owner/agent hereby agrees that it is his/her responsibility, and not the veterinarian's, to notify the insurance company as required by the terms of any applicable insurance policy. I have read and understand this authorization. To the best of my knowledge, the information I have provided is true. I understand that my wishes may be carried out immediately upon my signing this agreement. Fees for these services have been explained to me. Initials How did you hear about us? If you are having your pet individually cremated, PMPC will issue a certificate of cremation. How would you like your pet’s name displayed on cremation certificate? How would you like you or your family’s name displayed on cremation certificate? Payment Disclaimer I owner/agent of said pet above due understand the fees associated with euthanasia services and cremations services that I have requested for my pet. I owner/agent do understand and authorize staff or agent of Peaceful Partings to charge the $50.00 deposit which is required to reserve my stated appointment with Peaceful Partings, and I do understand that said $50.00 fee is nonrefundable if I decide to change or cancel the appointment for any reason. If a cancelation with in 2 hours of my appointment, the cancelation fee is $150.00. Initials Parking Notice Please note we need parking up in front of the home as close to the main entrance or where we will be visiting with your pet. Any damage or personal harm to staff or vehicle due to hazardous or inaccessibility to the home will be the responsibility of the homeowner. Initials Date Will you be picking up your pet’s ashes at Peaceful Memorials Pet Crematory? Yes No Submit Request & Wait for Scheduling Call