Owner's Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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)
Reset to re-sign.
Date
(Required)
MM slash DD slash YYYY
CAPTCHA
Notifications