Euthanasia Consent Form Consent to Perform Euthanasia Owner's Information Name Name First Name First Name Last Name Last Name Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone Email Pet Information Pet Name: * Species: * Cat Dog Exotic Breed: * Color: * Sex: * Male Female Neutered/Spayed? * Yes No Weight: * It is my desire to provide for my pet, decent and humane after passing care, that applies to the legal requirements of the area. I authorize the attending veterinarian, and affiliates (including Rainbow Bridge, Eco Cremation or Paws and Remember) to take charge of my pet's remains in accordance with our hospital policy. Signature * signature keyboard Clear Decision for Care of Remains Decision for Care of Remains: We also do FREE inked paw or nose prints upon request Private Cremation: I choose to get my pet's ashes returned to me. Additional costs will apply General Cremation: I choose to NOT have my pet's ashes returned to me. Take home option: Personal at home aftercare- owner please initial below Undecided I am undecided on cremation options for my pet(s) at this time. I give American Animal Hospital permission to hold onto my pet(s) for 10 days while a decision is made on cremation. As the owner or signer of this agreement I agree to the following: if not reachable after the 10 day hold or as the owner or signer I do not reach out to American Animal Hospital at or before the 10 days are done my pet will bе sent to Rainbow Bridge at the Nebraska Humane Society as a General cremation and NO ASHES WILL BE RETURNED TO МE. As a courtesy American Animal Hospital will try to reach out after the 10 days but if no response after a couple of days the 10-day cremation policy will go into effect and my pet will be sent to Rainbow Bridge. By signing, you agree to the Hold Consent Form: * signature keyboard Clear Owner's Choice Rainbow Bridge Paws and Remember Eco Cremation Don't Know / Undecided Signature All fees and services have been explained to me. I am aware that payment is due at time of service. Ialso certify that this pet has not bitten any person or animal in the last 10 days. By signing, you agree to the statement above: * signature keyboard Clear Submit If you are human, leave this field blank.
