I, the undersigned, do hereby certify that I am the owner or duly authorized agent for the owner of the animal described above, that I do hereby give the veterinarian and his/her employees or representative, full and complete authority to end the life and dispose of said animal in whatever manner they shall deem humanely appropriate.

I acknowledge that the veterinarian has met with me personally and discussed the euthanasia of my animal. I also certify that to the best of my knowledge, the said animal has no bitten any person or animal during the last fifteen (15) days, and has not been exposed to rabies. I further understand that I assume financial responsibility for all services rendered.

Again, by signing this form I am giving permission to end this animal's life and I have the authority to do so.

I wish to (please select one):

MM slash DD slash YYYY