Country Club Animal Hospital

PET OWNER:

PHONE NUMBER:

CELL:

PET'S BREED:

NAME:

PET'S COLOR:

I, (Insert your name), do hereby certify that I am the owner (or duly authorized agent for the owner) of the pet described above, and that I give the Doctors of Country Club Animal Hospital (CCAH), full and complete authority to euthanize my pet and dispose of my pet's body in one of the following manners:

MEANS OF CREMATION: (YES indicates means of Cremation)

General Cremation:

• A group cremation, pet’s ashes ARE NOT returned to owner

Private Cremation:

• A private cremation, pet’s ashes ARE returned to owner • CCAH will contact in reference to urn and name plate options

Furthermore, I release the Doctors of CCAH from any and all liability for euthanizing my pet and disposing of my pet's body. I do also certify that, to the best of my knowledge, my pet has not bitten any person or animal during the last ten (10) days, and that he/she has not been exposed to Rabies virus.

OWNER’S SIGNATURE:

Date

CCAH WITNESS TO SIGNATURE:

Date