Veterinary Referral Form Name of Referring Veterinarian Clinic Name Clinic Phone Number Clinic Email Address Name of Client (registered owner on file, who will be signing the euthanasia consent form) Family Members (names of any secondary owners that may be present for euthanasia, ie. spouse, children etc.) Primary Contact Phone Number Secondary Contact Phone Number Address Email Address Name of Patient Age Species Breed Color/Markings Gender Is the Patient Spayed/Neutered?YesNo Patient’s Weight Brief medical summary and reason for euthanasia How would you like us to proceed? Please contact the client as soon as possible.The client will contact you when they are ready
