Owner's Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
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Colorado
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Delaware
District of Columbia
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Guam
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Maryland
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Northern Mariana Islands
Ohio
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Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
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Wisconsin
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Pet's Name
(Required)
Species
Dog
Cat
Breed
(Required)
Color
(Required)
Sex
(Required)
Male
Male (neutered)
Female
Female (spayed)
Age/Date of Birth
(Required)
I, the undersigned, do hereby certify that I am the owner (duly authorized agent for the owner) of the animal described above; that I do hereby give Express Vets LLC, DVM, his/her agents, servants, and representatives full and complete authority to euthanize the said animal in whatever manner the said Doctor, his/her agents, servants, or representatives shall deem fit.
(Required)
I have read and understand
I do hereby, and by these presents, forever release the said Doctor, his/her agents, servants, or representatives from any and all liability for so euthanizing the said animal.
(Required)
I have read and understand
I do also certify that the said animal has not bitten any person or animal during the last fifteen (15) days, and to the best of my knowledge, has not been exposed to Rabies.
(Required)
I have read and understand
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
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