Decorative Metal Urn (Blue)

Hand-Carved Rosewood Urn

Cedar Memorial Urn

Blue Scattering Tube with Paw Prints

End of Life & Aftercare

Consent Form

Please fill out this form in its entirety. Once completed, a member of our staff will reach out to go over appointment details.

Appointment Location (Address)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Pet's Name

Pet's Birthday or Approximate Age

YYYY

Pet Species

Please select from the dropdown below

Pet's Breed

Pet's Color

Pet's Sex

Pet's Weight (lbs.)

Is the Pet Microchipped?

Owner/Authorized Agent's Name

First Name

Last Name

Owner/Authorized Agent's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Owner/Authorized Agent's Phone #

Country

(###)

###

####

Owner/Authorized Agent's Email

Ownership Certification

I certify that I am the legal owner, or the authorized agent for the owner, of the animal described above, and I have the authority to execute this consent to treatment.

Consent For Treatment

1. I have been informed that there are certain risks and complications associated with any veterinary medical intervention. 2. I understand that during the course of the treatment or procedures, unforeseen conditions may arise that may necessitate the performance of additional procedures. 3. I authorize the use of appropriate sedation, anesthesia and pain relief medication as needed. I have been informed that there are risks associated with the use of any medication.

Release of Liability

1. I understand that Over The Rainbow Bridge LLC provides hospice, palliative and end of life care that focuses on the relief of a terminally ill patient’s distress and symptoms during the final stages of life. 2. I understand that hospice care prioritizes comfort and quality of life by reducing pain and suffering. 3. I understand that hospice care provides an alternative to therapies focused on life-prolonging measures. 4. I understand and agree that neither Over The Rainbow Bridge LLC, nor any of its employees or volunteers, will be liable for any illness, injury, death, and /or escape of pet(s) provided that reasonable care and precautions are followed. 5. I hereby release Over The Rainbow Bridge LLC, and any of it’s employees or volunteers, of any liability of any kind whatsoever arising from or as a result of my pet(s) participating in in-home veterinary care and services.

Medical Condition Disclosure

Does your pet have any medical conditions, illness or diagnosis that Over The Rainbow Bridge LLC should be aware of?

If you selected yes above, please list the medical condition(s) & approximate date(s) when the condition(s) began

Veterinarian Update

Would you like Over The Rainbow Bridge LLC to update your pet's regular veterinarian or veterinary hospital?

If yes above, what is the contact information (Name, location & phone number) for your pet's regular veterinarian?

Consent for Euthanasia Procedure

1. I understand that euthanasia is the administration of medications that will end the life of a patient, for the purpose of limiting the patient's suffering. 2. I understand when euthanasia is complete, the patient will be deceased. 3. I request the DVM, Over The Rainbow Bridge LLC, and any authorized agents, staff, volunteers or representatives to complete the euthanasia process. 4. I give the DVM, Over The Rainbow Bridge LLC, and any authorized agents, staff, volunteers or representatives full and complete authority to euthanize and arrange for cremation of my pet, in a humane manner. 5. I forever release the DVM, Over The Rainbow Bridge LLC, and any authorized agents, staff, volunteers or representatives from any and all liability for euthanasia and cremation of my pet.

CT Rabies Law Compliance

1. I acknowledge that Connecticut state law requires post euthanasia rabies testing on any animal who has bitten people, or other animals, or been exposed to rabies virus in the last 10 days. 2. I certify to the best of my knowledge the patient has not bitten any person, or animal during the last 10 days and has not been exposed to rabies virus. 3. If the patient has bitten a person, or animal, or been exposed to rabies virus in the last 10 days, I understand that the patient must be tested for rabies virus after euthanasia. 4. I understand that remains cannot be returned to me after rabies testing.

Necropsy (Autopsy)

1. I understand that necropsy is a post-mortem examination, most often performed for the purpose of gathering more information on the disease processes and to determine the cause of death. 2. I understand that I have the option to have my pet’s remains submitted for necropsy to the Connecticut Veterinary Medical Diagnostic Laboratory, located at the University of Connecticut Campus in Storrs, CT. 3. I understand that the cost of transportation of my pet’s remains to the Connecticut Veterinary Medical Diagnostic Lab in Storrs, CT is $250. 4. I understand that Connecticut Veterinary Medical Diagnostic Laboratory administers its own necropsy fees.

I understand that my options concerning necropsy are: I can decline the option of necropsy or I can elect a necropsy with the acknowledgement and understanding that it may not be possible to have my pet’s remains or ashes returned to me.

Aftercare

I request that my pet’s remains be cared for in the following manner:

Individual Cremation

1. If individual cremation is elected, I understand that my pet's ashes will be returned to me via UPS signature required, directly from Final Gift Pet Memorial Center. 2. If individual cremation is elected, I understand that if I have any questions or concerns related to the return of my pet's ashes, or for UPS tracking information, Final Gift Pet Memorial can be contacted directly at: (203) 941- 2690, www.finalgift.com

If individual cremation is elected, I would like my pet's ashes returned to the address: (Signature Required For Delivery)

The urn I select for my pet's individual cremation remains is:

Medical & Financial Authority

1. 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 upon signing this agreement. 2. I understand the associated fees for these services. 3. If I am signing this as an agent, I certify that I have the authority to execute this consent.

Signature

Please type your name to certify your authorization and consent.

Date Signed

YYYY

End of Life & Aftercare

Consent Form

Thank you! Our Team will review the information you have provided and get back to you!

Over The Rainbow Bridge