AUTHORIZATION FOR FINAL DISPOSITION/AQUAMATION
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AUTHORIZATION This Authorization Form is required to be completed and signed prior to the final disposition of your pet. Aquamation IS AN IRREVERSIBLE AND FINAL PROCESS. It is important that you understand the Aquamation process and different options available prior to signing it. Please ask us any questions about the process you may have. I/We represent that I/We have the right to authorize the aquamation of the Pet’s remains and warrant that I/We are the Owner or an Agent of the Owner (“Authorizing Agent”). I/We have read and initialed all required Pet Disclosures as listed on the reverse side. I/We have read and understand the description of the different available aquamation processes described on the reverse side including the final disposition/return of aquamated remains; by initialing below, I/We authorize the following:

Select an option

SERVICES & MEMORIAL ITEMS

I/We have been informed of memorial items and choose (initial one): Items Selected Below
I/We would like the following memorialization items:

Service & Memorial Items

*(Private includes 1 fur clipping and 1 clay paw print. Additional fur clippings $15 each. Additional clay paw print $20 each)


NOTICE: Be Sure To Fill Out The Section Above And Indicate The Memorial Items Desired. San Diego Neighborhood Vet Will Only Provide The Memorial Items You Specifically Select Above.

RELEASE AND CERTIFICATION I/We agree to release and indemnify Peaceful Waters Aquamation, 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 Peaceful Waters Aquamation, 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 aquamation 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 pages of this document. Authorization for aquamation and disposition was executed at (San Diego, Calif.)

TERMS AND CONDITIONS FOR AQUAMATION AUTHORIZATION FORM AQUAMATION OPTIONS
Aquamation is performed to prepare the remains of the pet for final disposition. It is carried out by placing the pet into an Aquamation chamber where they remain for 20 hours while warm water and alkali breakdown the soft tissue, leaving only bone fragments (calcium compounds) and ketal medical devices. The Aquamation can be done in the following ways, including Individual; Communal; and Private. Due to the nature of the Aquamation process, any possessions or materials, such as collars or tags that are left with the animal will be removed prior to Aquamation and disposed of by Peaceful Waters Aquamation. The Authorizing Agent understands that arrangements must be made to remove any such personal possessions or materials prior to the time that the animal is transported to Peaceful Waters Aquamation. After the aquamated remains are removed from the Aquamation chamber, all inorganic material will be separated and removed from the animal bone fragments by visible selection. The Authorizing Agent understands and authorizes Peaceful Waters Aquamation to dispose of these materials in a non-recoverable manner, including recycling. When the aquamated remains are removed from the Aquamation chamber, the skeletal remains often will contain recognizable bone fragments. After bone fragments are dried, they will be mechanically processed, pulverized. The process of crushing or grinding may cause incidental commingling of the remains with the residue from the processing of previously aquamated remains. These granulated particles of unidentifiable dimensions, which are virtually unrecognizable as animal remains, will then be placed into a designated container based on the type of Aquamation identified above (Individual, or Communal). An INDIVIDUAL Aquamation is an Aquamation procedure during which one animal’s body is placed in a single stainless steel compartment inside the Aquamation chamber. The aquamated remains of that specific pet are to be returned. A COMMUNAL Aquamation is an Aquamation procedure where multiple pets are aquamated together without any form of separation. These commingled, aquamated remains are not returned to owners. WITNESSING an Aquamation can be an emotional experience. Witnesses are assuming the risks involved and fully release Peaceful Waters Aquamation from any liability. To the extent permitted by Peaceful Waters Aquamation, the persons identified on an Aquamation Witness Acknowledgment Form are authorized to be present during the placement of the animal’s remains at the Aquamation facility. Witnessing of any aspect of the Aquamation and processing procedure shall be in compliance with all applicable law and any safety regulations. If you desire witnesses, you must list the witness names, and all witnesses must sign an additional Aquamation Witness Acknowledgment Form. FINAL DISPOSITION OF AQUAMATED REMAINS Following the Aquamation, the Authorizing Agent directs Peaceful Waters Aquamation to undertake the actions set forth on the reverse side to arrange the final disposition of the aquamated remains. Remains shall only be released, delivered, mailed or scattered by Peaceful Waters Aquamation in a dignified manner, in accordance with the law, and with expressed written consent of the Authorizing Agent. If the aquamated remains are shipped at any time, the Authorizing Agent directs that the Resting Waters utilize registered U.S. mail with a return receipt or a shipping service that uses an internal system for tracing the location of the aquamated remains during shipment and requires a signed receipt of the person taking delivery of the aquamated remains. The Authorizing Agent understands that if no arrangements for the final disposition of the aquamated remains have been made within sixty (60) days after the Aquamation or if the Authorizing Agent has not taken delivery of or caused the delivery of the 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 Peaceful Waters Aquamation or Veterinarian, Peaceful Waters Aquamation or the Veterinarian may dispose of the aquamated remains in any dignified manner, including scattering.Peaceful Waters Aquamation is a business under Neighborhood Veterinary Corporation. PET DISCLOSURES (initial) LJS_ I/We further represent and warrant that the animal has not bitten any person or other animal during the past ten (10) days, is not suffering from Rabies, and has not been exposed to other animals suffering from Rabies.

Please also complete this online Authorization Form. Remember to submit upon completion.

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