Authorization for Services Name(Required) First Last Email(Required) Pet's Name(Required)Appointment Date(Required) MM slash DD slash YYYY Authorization(Required) This Authorization Form is required to be completed and signed prior to the treatment, euthanasia and/or final disposition of your pet. Euthanasia and Cremation are IRREVERSIBLE AND FINAL PROCESSES. I understand that euthanasia is the act of ending the life of an animal in a painless way to prevent unnecessary suffering. I understand that aquamation, also called alkaline hydrolysis or water cremation, is an eco-friendly alternative to fire cremation. I certify I am the legal owner or authorized agent for the owner of the pet described above and give Paws into Grace* and any authorized agents, staff or representatives full and complete authority to examine, prescribe, treat, euthanize and/or provide cremation services for my pet today and/or in the future. I forever release and hold harmless Paws into Grace and any authorized agents, staff or representatives from any and all liability for my pet’s treatment, euthanasia, and/or aftercare, including direct, indirect, or consequential damages resulting from comfort or end-of-life care. I understand Paws into Grace advises against restraining or holding my pet during any injections and I take full responsibility for the outcome.If I do not choose aftercare with Paws into Grace, I take full responsibility for all the aftercare arrangements myself. I am aware of laws and regulations regarding the burial of my pet and understand caution should be taken when handling a pet euthanized with drugs/chemicals. AfterCare Acknowledgement(Required) If I do not choose aftercare with Paws into Grace, I take full responsibility for all the aftercare arrangements myself. I am aware of laws and regulations regarding the burial of my pet and understand caution should be taken when handling a pet euthanized with drugs/chemicals. Cancellation Policy(Required) Paws into Grace must be notified no later than 2 hours before your appointment to avoid a cancellation/ rescheduling fee up to the full house call appointment price ($375 plus any travel fees). Release and Certification(Required) I/We agree to release and indemnify Paws into Grace, the Veterinarian, and their owners, members, officers, directors, agents, and employees, from any claim, liability, cost, or expense resulting from their reliance on or services or other performance consistent with the directions, declarations, representations, authorizations, and agreements herein. I/We agree that the liability Paws into Grace, the Veterinarian, and their owners, members, officers, directors, agents, and employees, including without limitation for negligent acts (of itself or its agents or employees), is limited to a refund of the cremations and/or house call fees paid by me/us. I/We warrant that all representations and statements contained in this form are true and correct. I/We have read and understood all parts of this document. Quality of Life/Comfort Care(Required) If I have scheduled a Quality of Life or Comfort Care appointment, or my appointment turns into a comfort care or quality of life appointment, I understand comfort care is focused on preserving quality of life for as long as possible and is NOT focused on curing medical conditions or providing routine veterinary care, surgical care and/or emergency treatment/transport. I assume full responsibility for the actions of the companion animal described above and all charges incurred during his/her comfort care. I have carefully read and fully understand the above provisions. I/we understand that incorrect usage, including accidental injection, of any/all prescriptions, medications and/or the treatment patch prescribed may cause illness up to and including death, which I acknowledge Paws into Grace is not liable for. I understand that diagnoses and prognosis are limited to the physical examination that the veterinarian is able to perform at my appointment. I acknowledge that further testing may need to be completed to receive an accurate diagnosis/prognosis. I also understand the physical examination of my pet is limited to their temperament and may not be performed if the pet is fractious or aggressive. Paws Into Grace has informed me if additional diagnostics, procedures and/or more aggressive comfort care are recommended for my companion animal at this time, and I assume all responsibility for additional diagnostics, procedures and/or more aggressive comfort care. If I choose to decline recommendations for additional diagnostics, procedures and/or more aggressive comfort care treatment, I assume all responsibility and will forever release and indemnify Paws into Grace. Final Disposition of Cremated/Aquamated Remains(Required) I understand that following the Cremation/Aquamation, the Authorizing Agent directs Paws into Grace to undertake the actions set forth on the reverse side to arrange the final disposition of the cremated/aquamated remains. Remains shall only be released, delivered, mailed or scattered by Paws into Grace in a dignified manner, in accordance with the law, and with expressed written consent of the Authorizing Agent. If the cremated/aquamated remains are shipped at any time, the Authorizing Agent directs that the Paws into Grace utilize registered U.S. mail with a return receipt or a shipping service that uses an internal system for tracing the location of the cremated/aquamated remains during shipment and requires a signed receipt of the person taking delivery of the cremated/aquamated remains. The Authorizing Agent understands that if no arrangements for the final disposition of the cremated/aquamated remains have been made or paid for within sixty (60) days after the Aquamation or if the Authorizing Agent has not taken delivery of or caused the delivery of the cremated/aquamated remains, or in the event the arrangements of the final disposition have not been carried out within the sixty (60) day period because of the inaction of a party other than Paws into Grace or Veterinarian, Paws into Grace or the Veterinarian may dispose of the cremated/aquamated remains in any dignified manner, including scattering. Paws into Grace is a business under Benson Veterinary Enterprises, Inc. PET DISCLOSURES(Required) To the best of my knowledge my pet has not bitten, scratched and/or potentially exposed any person or other animal to rabies in the past 10 days, is not suffering from rabies, and has not been exposed to other animals suffering from rabies. I understand that if the animal described above has bitten or otherwise potentially exposed any person within the time specified, a rabies test may be performed at my cost. CONSENT(Required) To the best of my knowledge the information I have provided is accurate and complete. Fees for these services have been explained to me and I assume full responsibility for all charges applicable to such services. I have carefully read and fully understand this form. Date Signed(Required) MM slash DD slash YYYY Signature(Required)Digital Signature(Required) I accept terms & conditions. Checking the box acts as my digital signature. Media Release OPTIONAL: I authorize Benson Veterinary Enterprises, Inc. permission to use my pets name, photos and likeness for publicity, copyright purposes, illustrations, advertising, and web content. (Media Release Authorization not required for service.)
