Euthanasiaforms in South Shore, Cape Cod and Islands

Today's Date*

Pet Owner's Name*

First Last

Spouse/Partner's Name (if applicable)

First Last

Address*

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

Phone - Best contact number*

Email*

How Did You Hear About Us:*

Pet's Name*

Pet's Age*

Dog or Cat?*

Pet's Weight*

Breed & Color*

Male or Female / Neutered or Spayed*

Please list Veterinarians and Pet Care Professionals who have seen your pet within the last three (3) years.

I certify that I am the legal owner (or duly authorized agent for the owner) of the animal described above, and do hereby give Dr. Paula Monte, Litchfield Animal Wellness, and any authorized agents, staff, or representatives full and complete authority to euthanize and handle after-care of said animal in a humane manner. I hereby forever release and hold harmless Dr. Monte, Litchfield Animal Wellness, and any authorized agents, staff, or representatives from any and all liability for euthanasia and disposal of said animal.

I also certify 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 ten (10) 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

I understand that euthanasia is the act of ending the life of an animal in a painless way to prevent any unnecessary suffering. To the best of my knowledge, the information I have provided is accurate and complete. I understand that my wishes may be carried out immediately upon my signing this agreement. Fees for these services have been explained to me, and I assume full responsibility for all charges applicable to such services. I have carefully read and fully understand the foregoing provisions.

After Care Arrangements*

I will handle and take full responsibility for all after care arrangements myself. I am aware of any applicable laws and regulations regarding the burial of a pet’s body and understand caution should be taken when disposing of animals euthanized with drugs/chemicals.
I wish to have Litchfield Animal Wellness arrange for my pet's aftercare

If you chose aftercare, please select one of the following.

Group Cremation - (no ashes returned) [pricing varies]
Individual Cremation - (ashes returned back to family) [pricing varies]

Additional Options Available With Aftercare:

Clay Paw Print Impression + $50/
Ink Paw Print + $35/
Ink Nose Print + $35/

If multiple of any memorial item is desired, please let Dr. Monte know.

Financial Policy*

I agree to the Financial Policy.

Thank you for choosing Litchfield Animal Wellness.
Our Mission is to provide the very best healthcare and service to our patients and their owners.
One way we accomplish this is to offer clients easy payment options.
Accepted Methods of Payment:
✓ Cash
✓ Check (Copy of Driver’s License required)
✓ Visa, MasterCard, American Express, Discover Card
Credit Cards are processed securely via Square
Policy Information:
Payment is expected at time of service. We prefer to devote our time to caring for our patients, as opposed to managing accounts.
Credit Card information can be called into the office and will be kept on file and will be charged if other payment arrangements were not discussed. Credit Card receipts can be emailed to the cardholder.
There will be a $75.00 fee for all returned checks.
A house call fee may be charged to any client that misses an appointment.
A $100.00 fee may be charged to any client that does not give at least 24 hours notice to cancel an appointment.
Agreement:
By checking above, you agree to the terms of payment.

Signature

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