Date MM slash DD slash YYYY Owner's Name: First Last Pet's Name: First PhoneI certify I am the owner, or authorized agent for the owner, of the pet described above. I agree I DO NOT agree I certify that the pet described above has not bitten or scratched any person or animal within the past 10 days, is current on its rabies vaccination and has not been exposed to an animal that is likely to have rabies. I agree I DO NOT agree I certify I am the owner, or authorized agent for the owner, of the pet described above. I agree I DO NOT agree When the euthanasia procedure is performed, you have the option to be with your pet. (Please select one) I WOULD like to be present during the euthanasia procedure. I understand that I will see an IV catheter in my pet’s foreleg. I WOULD NOT like to be present during the euthanasia procedure Please let us know your preferences for memorial keepsakes. (Select all that you wish to recieve) I would like to have an ink print keepsake. ($26.50) I would like to have a clay keepsake paw print. ($26.50) I would like to have a lock of hair memory keepsake. ($11.00) Please let us know your wishes following their passing. (Please select one) I will be taking my pet’s body home for burial. I would like to leave my pet’s body for communal cremation, and I will not receive the ashes back. I understand my pet’s ashes will be buried in the Cabarrus Funeral, Cremation & Cemetery in Concord, North Carolina. I agree to the additional cost of ($150.00) I would like my pet to be individually cremated and to have my pet’s ashes returned to me in an urn. I agree to the additional cost of ($345.00) If you have selected to have your pet individually cremated and the ashes returned, would you like your pet’s urn to be engraved? (No additional charge) If so, please type below what you wish to be engraved. Some ideas are your pet’s name, a meaningful Scripture verse, etc. If you would not like the urn to be engraved, then please typle “N/A” in the section below.Typed SignatureI certify that I am the owner of the above-named pet. I hereby give my consent and authorize the veterinarians and team at Johnston Animal Hospital to perform the euthanasia of my pet. I understand that a health care plan will be provided for my review at the time of admission. I acknowledge and accept responsibility for payment in full for all services at the time of my arrival.
