Euthanasia/Body Care Authorization and Medical Record Pet Euthanasia - Body Care Authorization - COVID Pet's Name * First Name * Last Name * Partner/Spouse full name Best Phone * Mobile phone if "best" phone is not mobile Email * Confirm Email * Physical Address * Physical Address Physical Address Physical Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Physical Address is: * Physical and Mailing Physical only Mailing Address * Mailing Address Mailing Address Mailing Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Primary Care Veterinary Hospital * Affirmations and Declarations Medical Decisions * I am authorized to make medical, euthanasia, and body aftercare decisions for the above referenced pet. Euthanasia Request * I authorize and request euthanasia for the above referenced pet. Pet's Biting History * Yes, this animal has bitten a person or animal in the past ten (10) days. No, this animal has not bitten any person or animal in the past ten (10) days. Body Care Options Body Care Options * Private Cremation Group/Communal Cremation I Will Keep the Remains Keeping the Remains * I will keep the remains for burial or other arrangement in accordance with local ordinances for environmental and wildlife safety. I understand that medications used are toxic to other animals including wildlife and groundwater. Group/Communal Cremation * I understand that the ashes will not be returned to me. Private Cremation * I will pick up the ashes at Corner Gateway Business Service Center, 1972 New Scotland Road, Slingerlands, NY 12159 (no additional charge) UPS delivery directly from cremation provider ($30 fee). Visiting Doctor * Dr. Roger Blankfein Dr. Amanda Craig Dr. Katie Tuffey Dr. Carlin Jones Please indicate the doctor with whom you have scheduled an appointment. Today's Date Signature Clear reCAPTCHA If you are human, leave this field blank. Submit
