End of Life Care - Touhy Animal Hospital

Your Name*
First Last
I certify that I am the owner or the authorized agent for the owner of the pet described above and give Touhy Animal Hospital, the doctors and staff full and complete authority to euthanize my pet. I understand that euthanasia is the act ending the life of an animal in a painless and humane way.*
- I certify
Please select a package:*
- I choose Going Home Cremation Package: I understand that my beloved pet will have a private cremation performed at our crematory without family and friends present. This package includes a brass slate urn, a pendant and link chain, and a clay paw print of beloved pet with pets name embossed in clay
- I choose the Always Remembered Cremation Package: I understand that my beloved pet will have a private cremation performed at our crematory without family and friends present. This package includes either a copper, oak wood or cherry wood urn.
- I choose Group Cremation: I understand that my beloved pet will be cremated along with other pets and ashes will not be returned.
- I would like total _____ (quantity) clay paw print keepsake(s) for $22, or (buy 2 get 1 free at $44)
Total (quantity)*
Pendant*
- I choose to receive a pendant
- I decline to receive a pendant.
Clay paw print:*
- I choose to receive a clay paw print.
- I decline to receive a clay paw print.
You will be notified in 7-14 days by Touhy Animal Hospital when the ashes have been returned from the crematorium for pick up in an urn.
Please select one:*
- I choose the tin urn
- I choose the oak wood urn
- I choose the cherry wood urn.
You will be notified in 7-14 days by Touhy Animal Hospital when the ashes have been returned from the crematorium for pick up in an urn.
Authorization*
- To the best of my knowledge, the information I have provided on this form is true. I do also certify that my animal has not bitten, seriously scratched or exposed anyone to or has been exposed to rabies within the past 10 days.
I understand that my wishes will be immediately carried out upon signing this agreement. Fees for these services have been explained to me and will be collected at the time of service.*
- I Understand
Signature*
Date*
MM slash DD slash YYYY
Phone
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