EUTHANASIA CONSENT FORM

Client Details
Pet Owner's Name:: First Name:
Last Name:
Phone:
Address:: Line 1:
Line 2:
City:
Country:
State:
Postal Code:
Pet's Name:
Pet's Age:
Gender:: MaleFemale
Colour:
Breed:
De-sexed:: YesNo
Weight:
Consent
: I, the Owner / Authorised Representative of the above mentioned animal and authorise a qualified person from the Quality Veterinary Care Centre to perform euthanasia for the above described animal.
In consideration of Quality Veterinary Care Centre providing this service. I agree to pay the prescribed fees.
I further agree to underwrite Quality Veterinary Care Centre and personnel from any loss or liability which they may incur as a result of any inaccuracy whether intended or otherwise in this declaration.
By signing this form, I/We agree that…
i. All questions by us have been answered satisfactorily;
ii. I/We have read and understood this document;
iii. Authorise and consent is given as required;
iv. Agree to QVCC’s payment terms and conditions;
v. Aware that all payments are due at the time of service;
vi. Agree to be personally responsible for all professional fees as rendered by QVCC;
vii. Aware that whilst all care is taken by QVCC, I/We have had the risks explained and hereby indemnify and keep indemnified QVCC and employees against claims howsoever arising.
Name of Owner / Authorised Representative:
Owner's Signature / Authorised Representative:
Witness Name:
Witness' Signature:
Date: