Client's Name(Required) First Last Client's Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Client's Phone(Required)Your Pet's Name(Required)My pet is a(Required) Canine FelineBreed(Required)Age(Required)Color(Required)Consent(Required) I, the undersigned, do hereby certify that I am the owner (or duly authorized agent for the owner) of the animal described above. I hereby give the doctors of Queenstown Veterinary Hospital permission to euthanize and dispose of said animal in a manner in accordance with my wishes and abiding by local ordinances. I release the doctors, Queenstown Veterinary Hospital, their agents, servants and representatives of any and all liability for euthanizing and disposing of said animal. I certify that to the best of my knowledge the said animal has not bitten any person or animal during the prior ten (10) days and has not been exposed to rabies.Owner of Authorized Agent of Owner's Signature(Required)Your NameYour NameYour NameYour NamePlease select your preference(Required) Private Cremation Group Cremation Owner to take remainsCAPTCHAΔ
