End of Life Consent FormPet's RecordsOwner Name First Last PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Pet's NameEuthanasia ConsentConsent I, the undersigned, am the owner or duly authorized agent of the pet described above, that I am 18 years of age or older and do hereby give The Bronx Veterinary Center and any doctors employed there full and complete authority to humanely euthanize said pet and release the veterinary facility for any and all liability for euthanizing said pet.SignatureReset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY Authorization for disposition of pet’s remainsPick One Private Cremation: Your beloved pet is placed in a private crematory chamber with a third party company. The remains are then placed in an urn of your choice and delivered back to the Bronx Veterinary Center for pick up. You will have 6 months to pick up your pet’s ashes. Communal Cremation: Your beloved pet is cremated in a group setting with other pets. Ashes are not returned but receive a proper burial. Release remains: The beloved pet’s ashes will be released to the owner for proper disposition. (Local laws apply). I also release the Bronx Veterinary Center of all responsibility for disposing of the remains of my beloved pet.SignatureReset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY Δ
