Euthanasia/Body Care Authorization and Medical Record Pet Euthanasia - Body Care Authorization 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 Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 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 Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 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 pet 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 Transport Body to My Specified Veterinarian for 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. Transport * Indicate the veterinarian with whom you have pre-arranged to transport the body directly from home to practice and to be received during business hours. 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). Personal doorstep drop off (by special arrangement; fees vary) Visiting Doctor * Dr. Roger Blankfein Dr. Amanda Craig Please indicate the doctor with whom you have scheduled an appointment. Today's Date Signature Clear reCAPTCHA Submit If you are human, leave this field blank.
