Client Information

Name*

Prefix First Last

Email*

Phone*

Address*

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

Patient Information

Pet's Name*

Presenting Condition*

Pet's Date of Birth*

MM

DD

YYYY

Species*

Breed*

Color*

Sex*

Pet's Weight*

Authorization for Humane Euthanasia Services

Euthanasia Authorization*

I am the legal owner or duly authorized agent for the owner of the animal described above and do hereby give House Call Vet RVA, PLLC and the veterinarian licensed to perform euthanasia, Dr. Kaitlyn Hemsley, full and complete authority to euthanize and dispose or arrange for cremation of said animal in a humane manner. I hereby forever release Dr. Kaitlyn Hemsley, DVM, of the facility, House Call Vet RVA, PLLC, from any and all liability for euthanasia and disposing of said animal.

by checking this box, I have read and understand the above authorization for euthanasia and release all liability as stated above*

Euthanasia Protocol and Policies*

House Cal Vet RVA, PLLC and the licensed veterinarian performing euthanasia services, Dr. Kaitlyn Hemlsey, to choose a euthanasia protocol at their sole and exclusive discretion. I understand that any questions or concerns regarding euthanasia services requested for the animal listed above should be asked prior to signing this consent.

I agree and consent*

Rabies Exposure*

I do certify to the best of my knowledge the animal listed above has not bitten, seriously scratched, or exposed anyone to rabies within the past l0 days. I am aware that Virginia law requires proof of prior rabies vaccination and may require post euthanasia rabies testing of any animal who has bitten a person(s) or another animal or been exposed to a rabid animal or person(s) within the past 10 days. Remains cannot be returned after rabies testing. Ashes may be returned if requested below.

by checking this box, I have read and agree to the above statement and state law requirements*

I request that this animal's remains be cared for in the following manner*

Private cremation with return of ashes
Cremation with no return of ashes. My pet's remains will not be retuned to me.
Home burial. I wish to keep mu pet's body at home for my own burial.

Return of Pet's Cremains

I will pick the cremains at Agape Pet Services: 1001 Techpark Place, Sandston, VA
I would like my pet's cremains shipped to my home

Financial Policy*

Payment is due, in full, prior to the appointment date/time. I assume responsibility for all charges incurred in the care of the animal. I understand I will be responsible for additional collection fees if unpaid account is sent to collection agency. Accepted payment methods include cash, debit card or credit card (VISA, Mastercard & American Express). I am aware that estimates are provided upon request.

Owner/Agent's Signature*

I have read and understand this authorization. To the best of my knowledge, the information I have provided is true. I understand that these services will be carried out at the scheduled or agreed upon appointment time.

Name*

First Last

Date of Authorization*

MM

DD

YYYY

Electronic Signature Agreement

The parties agree that the electronic signatures appearing on this form are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

By signing and typing my full name below I agree to signing this authorization form electronically.*

Name*

First Last

Comments

This field is for validation purposes and should be left unchanged.

Euthanasia Consent Form