Euthanasia Consent Please review Radiant Heart After-Care options prior to completing form- https://radiant-heart.net/ Euthanasia Consent Form The decision to euthanize a dearly loved pet is one of the most emotionally trying moments experienced by any devoted owner. We understand this and make every effort to guide you through the process of end of life decisions, while always ensuring your pet’s final days are as comfortable as possible. By completing this consent form in advance of the euthanasia appointment, you will be able to give your full focus to your pet during the procedure. Scheduled Date of Euthanasia* Date Format: MM slash DD slash YYYY Client Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Please enter the Email address you wish us to send this signed consent form on completion.Phone*Patient Name* Pet's Name Patient Age*Estimate age if birth date unknown.Patient Species*CanineFelineOtherPatient Sex*MaleFemaleWeight*Please list your pet's approximate weight in pounds.Please describe your pet's distinct color markings and breed.*Electronic Euthanasia Consent- Please read carefully*By digitally signing this form, I certify that I am the owner or authorized agent of the animal listed. I release this animal to Fairhaven Veterinary Hospital and request euthanasia be performed. I understand that my request will be carried out upon signing this digital document.I confirm my pet has not bitten or scratched anyone in the last 15 days and has not been exposed to rabies, please proceed with the euthanasia of animal listed.I disagree- do not proceed with the euthanasiaPlease choose how you wish the remains cared for.*Transfer body to Radiant Heart After-Care ServicesReturn body to me for burialAfter-care cremation and aquamation services are provided by Radiant Heart located in Bellingham. All fees for cremation services are payable to Radiant Heart.Would you like your pet's cremated remains returned to you?*YesNoWould you like an after-care package?*YesNoYou have elected to not have your pet's remains returned to you. You may still request an after-care package. Please review after-care packages on Radiant Heart's website-https://radiant-heart.net/services-and-pricing/What type of Ink Print would you like with your after-care package?*NosePawBoth (+$35)Please select desired type of cremation service.*Water Cremation (Aquamation)Flame CremationPlease select the type of urn you would like.*Wood UrnBio UrnWould you like an after-care package?*YesNoWhat type of Ink Print would you like with your after-care package?*NosePawBoth (+$35)May a Radiant Heart representative contact you to confirm your after-care selections and collect payment?*YesNoRadiant Heart will make contact within 24 hours of delivery of remains to confirm your selection and facilitate payment.Please choose Radiant Heart payment method.*CheckCredit CardYou have asked that Radiant Heart not contact you prior to performing services. Payment is required prior to any after-care services being completed. If check payment is selected, be sure the check is made to Radiant Heart and for the correct balance. Checks must be provided to us at time of euthanasia and we will pass along to Radiant Heart.Credit Card Number*Please enter the credit card number.Credit Card Expiration Date*Please enter as mm/yyCVC Code*Please enter 3 digit code on back of card.Billing Zip Code*Please enter billing zip code for credit card.NameThis field is for validation purposes and should be left unchanged.