Euthanasia Consent Form: Do you have an upcoming appointment? Prepare ahead by filling out the following consent form. If you don’t have an appointment yet, please wait to fill this form out until an appointment has been scheduled. To schedule an appointment please call (570) 906-4129. Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Date of your scheduled appointment: * MM DD YYYY Pet's Name * Sex * Please Select One Male Female Pet's Age * Species * Dog Cat Other Breed * Color * Approximate Weight * Has your pet ever showed signs of aggression towards new people or a veterinarian? * Yes No How did you hear about us? * Referral from a clinic Referral from a friend or family member Facebook Google Our sign in Hamlin Our billboard on the Casey Highway Our billboard in Dickson City Our billboard in Hawley Our billboard in Clarks Summit Our billboard in the Wilkes-Barre area I am a current Buffalo & Beyond client Name of the friend or clinic that referred you: Pet's Main Illness / Concern: * Special Notes or Requests for the Veterinarian: Aftercare Preference * Please Select One Private cremation with return of ashes. Picked up during one of our Tuesday evening pick up times (5:30pm-6:30pm) Private cremation with return of ashes. Shipped direct from our crematory for a flat rate of $25. Cremation with no return of ashes. I understand that my pet’s remains will not be returned to me Home burial If shipping ashes please add UPS address below Additional Memorial Keepsakes Select any additional memorial keepsake item(s) you would like to add. One Paw Pals Paw Print is included with every appointment free of charge. Paw Pals Paw Print: Additional $10 each Baked Clay Paw Print: $25 each Framed Ink Print: $30 for only Paw Print (Only Available with Private Cremation & Must Be Picked Up At Our Office) Framed Ink Print: $30 for only Nose Print (Only Available with Private Cremation & Must Be Picked Up At Our Office) Framed Ink Prints: $50 for both a Paw Print & a Nose Print (Only Available with Private Cremation & Must Be Picked Up At Our Office) Name of your pet's primary veterinary clinic: * Preferred Payment Method * Cash Credit Card Check I, the undersigned, certify that I am the owner or duly authorized agent for the owner, of the animal described above. I do hereby give Buffalo & Beyond Veterinary Services, PLLC Veterinarians, staff and agents complete authority to euthanize the animal described above. I release Buffalo & Beyond Veterinary Services, PLLC Veterinarians, staff and agents from any and all liability for euthanasia of said animal. I understand that euthanasia involves administering an intravenous injection of sodium pentobarbital causing painless and irreversible death to the animal described above. I certify, to the best of my knowledge, the above animal has not bitten any person or animal during the last 10 days and has not been exposed to rabies. * Type your name above to digitally sign and check this box to confirm you have read & consent to the statement above * 24 hour cancellation policy: Our schedule runs very full so to ensure we are able to sufficiently care for as many pets as possible, please make us aware of any cancellations prior to 24 hours before your scheduled appointment. There is a $100 cancellation fee if less than 24 hour notice is given on cancelations. * Please check the box to confirm Winter Weather Protocol: Throughout the winter season, we kindly ask that you maintain a clear path from your driveway or street parking to your residence, enabling Dr. Sverduk's safe access for appointments. For pet transport, ensuring our vehicle's proximity to your home is crucial. If needed, moving a vehicle for easier access would be greatly appreciated. * Please check the box to confirm Date * MM DD YYYY Thank you for filling on your pet’s euthanasia consent form!