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| Issues > Policy > AVMA model euthanasia authorization |
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| AVMA policy |
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| AVMA Model Euthanasia Authorization |
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(Approved by the AVMA Executive Board 1999; revised November 2004; revised April 2006)
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Date:______________ Case / Patient ID: _________________________________________
Client Name:___________________Client's Driver's License No:_______________________
Address:____________________________________________________________________
Home Phone:_______________________ Work Phone:______________________________
Animal Name / ID:____________________________________________________________
Species:____________________________________________________________________
Breed / Variety: ___________________________ Sex: [ M ] [ F ] Altered: [ Y ] [ N ] [ U ]
Age:_______ DOB:_____________ Weight:________ Colors: _________________________
Markings:____________________________________________________________________
Traceable ID / Microchip: [ Y ] [ N ] _______________________________________________
Tattoo: [ Y ] [ N ]: If Yes, location and description of tattoo:
_____________________________________________________________________________
I certify that I am the legal owner/duly authorized agent for the owner (circle one) of the animal described above, and do hereby give Dr. _________________, the __________________ Veterinary Hospital and any authorized agents, staff, or representatives full and complete authority to euthanatize and dispose of said animal in a humane manner. Unless otherwise agreed upon, disposition of the body of said animal is left to the judgment of the veterinarian. I hereby forever release Dr. _______________, the ________________ Veterinary Hospital and any authorized agents, staff, or representatives from any and all liability for euthanasia and disposal of said animal. Cautions should be taken when disposing of animals euthanized with drugs/chemicals.
Dogs, Cats and Ferrets: To the best of my knowledge, the dog, cat, or ferret described above has not bitten, scratched, or otherwise potentially exposed any person or other animal to rabies in the past ten (10) days. Other Species: To the best of my knowledge, the animal described above has not bitten, scratched, or otherwise potentially exposed any person or other animal to rabies in the past thirty (30) days.
I understand that if the animal described above has bitten or otherwise potentially exposed any person within the time specified, a rabies test must be performed.
If the animal described above is insured under a mortality insurance policy or any other type of insurance policy, the owner/agent hereby agrees that it is his/her responsibility, and not the veterinarian's, to notify the insurance company as required by the terms of any applicable insurance policy.
I have read and understand this authorization. To the best of my knowledge, the information I have provided is true. I understand that my wishes may be carried out immediately upon my signing this agreement. Fees for these services have been explained to me.
Owner/Agent's (circle one) Signature:__________________________Date: ________________
Verbal/Phone release granted by/to:_____________/_____________Date: ________________
Agent Clinician
Witness Signature:________________________________________ Date: ________________
I certify that if I am signing as an agent, I have the authority to execute this consent.
Name: _______________________________________________
(Please Print)
Signed: ______________________________________________ Date: ___________
(Signature of Authorized Agent)
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American Veterinary Medical Association
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