Name *

First Name

Last Name

Phone *

(###)

###

####

F

M

I certify that I am the owner or authorized agent of the owner, for the above-named animal. In being the owner/agent for this animal, I do hereby give Madrona Veterinary Housecalls, PLLC full and complete authority to perform euthanasia services. Arrangements for aftercare will be based on the wishes of the owner/agent and documented below. I release the above-named animal to Madrona Veterinary Housecalls, PLLC for:

Euthanasia - humanely terminate life

Aftercare Options *

If you select cremation services, Radiant Heart will contact you to confirm your selection. If you would like to purchase any additional products, you may do so directly through them at that time. Check radiant-heart.net for more information.

Private cremation with Radiant Heart Aftercare (Cremains returned, see below)

Communal cremation with Radiant Heart Aftercare (No cremains returned)

I choose to retain my pet for burial (Regulations for burial will be discussed)

Private cremation pickup options (if applicable)

I will pick up the cremains at Radiant Heart Aftercare (801 W Orchard Dr STE 3, Bellingham, 98225)

Please deliver to address indicated below (additional fees may apply):

To the best of my knowledge, the information I have provided on this form is true. I do also certify that this animal has not bitten, seriously scratched, or exposed anyone to rabies within the past 10 days. I understand that my wishes will be carried out after signing this agreement. I have reviewed fees for these services and would like to pay: *

By invoice prior to service

By check (preferred), cash, or credit card at the time of service

Health & Safety *

I agree to have a mask available for anyone present who has experienced upper-respiratory symptoms in the past week.

Date

MM

DD

YYYY