EUTHNASIA FORM CLIENT INFORMATION First Name* Last Name* Telephone number* PATIENT INFORMATION Pet's Name* Please Select* DogCatOther Please Specify* Reason for euthanasia Please SelectSickOld AgeBehavioralother Cremation Requested*:Please SelectPrivate CremationGroup CremationNo Cremation Requested I hereby certify that I am the owner of the animal described above I hereby give Wellness Veterinary Clinic full authority to euthanize my animal I hereby release Wellness Veterinary Clinic for any and all liability for euthanizing the said animal. I hereby certify that the said animal has not bitten any person or other animal during the last five days and to the best of my knowledge has not been exposed to rabies. Signature
