Date *

Owner Name *

First

Last

Mailing Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Physical Address (if euthanasia to be performed at home)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone Number *

Email *

Pet's Name *

Species *

Breed *

Sex *

Spayed or Neutered: *

Age *

Color *

I would like the euthanasia performed:

In clinic
At home (additional cost)

*Please email vitalityvet2019@gmail.com or call 306-782-8387 for price inquiries*

Consent:

I, the undersigned, hereby state that I am the legal owner/legally authorized representative of the legal owner of the above listed pet and authorized to make all medical decisions regarding this pet. I have declined any further care for the above pet and am hereby authorizing Vitality Veterinary Services to euthanize the above listed pet.

I agree to have Vitality Veterinary Services choose a euthanasia protocol at their sole and exclusive discretion and have had all my questions and concerns regarding this process answered prior to signing this consent.

I verify that the above listed pet has not bitten any person or animal or displayed any signs of unusual attitude or aggression in the last ten (10) days, and to the best of my knowledge has not been exposed to rabies.

It is my desire to provide for my pet decent and humane after-death care, complying with all legal requirements of the area. I authorize Vitality Veterinary Services to take charge of my pet's remains in accordance with hospital policy, releasing the hospital, doctor, and agents from any and all liability for performing said after-death care.

Signature of Legal Owner *

Clear Signature

By signing here, you are agreeing to having read and understood the consent above.

Date *

Requested method of aftercare:

Private cremation with return of ashes - I wish to have my pet individually cremated offsite and to have the cremains returned in the option I choose. See "Private Cremation Options" below for urn selection.
Cremation with no return of ashes - My pet's remains will not be returned to me.
Home burial - I wish to take my pet's body home. By choosing this option you agree that you either live or have a place outside of city limits where you are able to properly dispose of the body. Proper disposal means that after your pet is euthanized with barbiturates you are able to bury the body at least six feet underground in order to prevent inadvertent exposure to people, wildlife, or water supply.

Private Cremation Options

When opting for cremation, all remains are sent to Precious Pet Cremation based out of Winnipeg, MB. Your cherished companion will be treated with the same care, dignity, and respect that any person would expect to receive. Precious Pet Cremation guarantees that the cremains you receive back from their private cremation service will be that of your family pet and only your family pet. Please note that it takes 2 - 4 weeks for ashes to be returned to the clinic.

The following are the options to choose from:

Scatter Box - no urn; ashes are returned in a small cardboard box
Specialty Urn - please refer to Precious Pet Cremation's website for up to date specialty urn options: https://preciouspetcremation.com/urn-gallery.html
Ceramic Urn - these urns come in four colors

Type of specialty urn chosen (please be sure to include the size or any extra options such as engraving, etc.)

urn selection

Type of ceramic urn chosen:

Black
Mother of Pearl Black (subtle swirly appearance)
White
Mother of Pearl White (subtle swirly appearance)

*Please email vitalityvet2019@gmail.com or call 306-782-8387 for price inquiries*

Signature *

Clear Signature

Date *

New clinic location coming Spring 2025

Small Animal Euthanasia Consent Form