Client Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Email *

Pet's Name *

Species *

Canine
Feline

Breed *

Sex

Male
Female

Age/Date of Birth *

I request that remains be cared for in the following manner: *

Home Burial: I wish to take animal home with me for burial or have other disposition arrangements.
Communal Cremation - Ashes will not be returned to me: I wish to have animal cremated with other animals and understand that the ashes will not be returned to me.
Private Cremation - Ashes will be returned to me: I wish to have individually cremated at West Coast Pet Memorial. I understand that Southgate will contact me to arrange the return of 's ashes to me.
Hold: I wish for Southgate to hold my pet and agree to a deposit equivalent to the cost of private cremation. If I choose another means of disposition, the charge will be refunded to me. I understand that I have 72 hours to contact Southgate regarding my final wishes.

Southgate Animal Clinic staff is committed to providing with compassionate aftercare as well as offering our support to you and your family during the difficult time. If you have a special request for the care of your pet, please do not hesitate to ask. We will try to accommodate your wishes in any way that we can.

In addition to my above choice, I would like:

Clay Paw Print $23 *

Yes
No

Hair clipping *

Yes
No

I am the owner of the above-named animal or am legally responsible for its care and have the authority to request euthanasia. I do hereby give Southgate Animal Clinic representatives permission to perform humane euthanasia on this pet, thereby releasing Southgate Animal Clinic and its representatives of any liability associated with said euthanasia. I also give permission to dispose of this pet in accordance with clinic policy, thus releasing, representatives from any liability pertaining to disposal of said animal. I also certify that the above-named animal has not bitten any person or animal during the last 10 days and to the best of my knowledge has not been exposed to rabies. *

I understand and agree

Today's Date *

Phone

Email

Online Pharmacy

End of Life Authorization Form

End of Life Authorization Form

In addition to my above choice, I would like:

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