Euthanasia Certificate

"*" indicates required fields

Owner's Name:*

First Last

Today's Date:*

Owner's Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Owner's Phone:*

Owner's Email*

Animal Name:*

Date of Birth:*

List*

Sex:

Breed

Color

I, the undersigned, certify that I am the owner or duly authorized agent for the owner of the animal described above. I hereby give the doctors, agents, servants, and representatives of Deason Animal Hospital Inc. full and complete authority to euthanize and dispose of said animal in whatever manner they deem fit. I also release the doctors, agents, servants, and representatives of Deason Animal Hospital Inc. from any and all liability for so euthanizing and disposing of said animal.

If Deason Animal Hospital is temporarily holding your beloved pet, your pet will need to be picked up within 3 working days.

In addition, I certify that, to the best of my knowledge, said animal has not bitten any person or animal during the past ten (10) days, and has not been exposed to rabies.

Your Name:*

First Last

Your Signature:*

Date Submitted:*

For Hospital Staff Use Only (Do Not Select)

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Phone

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