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Euthanasia Consent Form
Thank you for choosing us!
Please complete this form to update us about your pet!
Please note: fields with a * are required.
Owner's Name
(Required)
First
Last
Email
(Required)
Address
(Required)
Street Address
Address Line 2
City
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Armed Forces Americas
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State
ZIP Code
Phone
(Required)
Pet's Name
(Required)
Pet's Age/Date of Birth
(Required)
Sex
(Required)
Male
Male (neutered)
Female
Female (spayed)
Species
(Required)
Dog
Cat
Breed
(Required)
Approximate Weight (lbs.)
(Required)
Name or primary veterinarian and any additional veterinarians who care for your pet:
(Required)
I request that my pet’s remains be cared for as follows:
(Required)
Private cremation with the ashes returned to me: (please see options for how you wish to receive the ashes and what type of urn you'd like below).
Communal cremation (no ashes return)
I will handle my pet’s remains by home burial or other arrangements
This field is hidden when viewing the form
Private Cremation
If you choose private cremation, you may select one of the following urns, which are included in the price of cremation. Additional urns are available for purchase directly from Agape Pet Services at agapepetservices.com.
(Required)
Remembrance Urn
Cedar Memorial Urn
Serenity Photo Urn
Hand-carved Rosewood Urn
Cream colored decorative metal urn
Gray decorative metal urn
Scatter tube
I do not want an urn or plan to purchase a different option from Agape
Click here to view urn options.
Please Note: If your primary veterinarian is outside our service area as defined by the map, or if it is Huguenot Veterinary Hospital, we can not return your urn to the vet hospital.
If you have chosen private cremation, you may enter up to 3 lines of text to be engraved, (30 characters per line) on a plaque (wooden urns) or 2 lines of text (25 characters per line) directly onto the urn (metal urns).
For private cremation, we have several options for returning your beloved pet’s cremains to you afterward. Unless previously arranged with Agape, the cremains usually take 1-2 weeks to be returned. Please choose an option that works best for your family below:
(Required)
Returned to my primary veterinarian (you must provide a name for the hospital above) at no additional cost. We will notify you when they urn and cremains have been delivered.
Hand delivered to my home (additional $15-125 depending on location, similar to the travel fee quoted). We can’t hand deliver urns to families who live more than 40 miles from Maymont/Byrd Park area
Shipped to my home via UPS for an additional $55
I will pick my pet’s remains up directly from Agape Pet Services at 1001 Techpark Place, Sandston, VA 23150 at no additional cost.
This field is hidden when viewing the form
End Private Cremation
If your pet weighs more than 40 lbs and you choose cremation, you or someone present will be able to help carry the stretcher to the doctor’s vehicle afterwards.
(Required)
I have read and understand
Would you like us to provide a memorial item to leave with you after your pet passes? (a fur clipping and the one paw pals impression print are included with our service and $24 for additional paw pals prints).
(Required)
Paw pals impression print: complimentary if you would like one
Fur clipping-complimentary/included
Additional paw pal prints (specify below)
No thank you, I do not want fur clippings or any paw prints.
Click here to view Paw pals impression prints.
How many additional prints would you like?
(Required)
1
2
3
4
5
Other
How many additional prints would you like?
(Required)
I am the owner (or authorized agent of the owner) of the animal described above. I hereby order and give Lovingkindness Veterinary Care and its personnel complete authority to euthanize my pet in whatever humane manner they deem appropriate and to care for their body afterward as specified above and in accordance with their policy. I hereby forever release Lovingkindness Veterinary Care and its personnel from any liability that may arise from euthanizing or handling of my pet.
(Required)
I have read and understand
To the best of my knowledge, my pet has not bitten any person or animal during the past ten (10) days, nor has my pet ever been exposed to rabies.
(Required)
I have read and understand
Our doctors and staff want to support you and your family through this process as best as we can, including afterwards. We try to follow up or reach out in a way that is most helpful and least obtrusive. Please select how you would feel most supported and comfortable hearing from us afterwards.
(Required)
A follow up email within 48 hours from our team.
A follow up text within 48 hours from our team.
I do not wish to be contacted by Lovingkindness Veterinary Care after my appointment.
Would you like a note in the mail from your doctor expressing their sympathy?
(Required)
Yes
No
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
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Name
This field is for validation purposes and should be left unchanged.
