Procedure Consent Form

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Client Details

Name *

First

Last

Email *

Animal Details

Name *

Species *

pet while and/or

What the pet has been admitted for *

Best number to be reached today for unexpected changes to the procedure: *

Additional phone number if you aren't able to be reached: *

If I am unable to be reached while my pet is under anesthesia, I consent for the veterinarian in charge to make the necessary medical decisions as needed. This may include extractions and/or additional medications and would incur additional costs of up to $500.00. *

In the event that my pet’s heart stops while at the hospital, I would like the medical team to: *

CPR (Cardiopulmonary Resuscitation): I authorize the veterinary team to perform life-saving measures such as chest compressions, medications, and/or intubation to try to restart my pet’s heart and breathing.
DNR (Do Not Resuscitate): I do not want resuscitation efforts to be performed. I understand that this means the medical team will allow natural death to occur without intervention.

Has your pet eaten after 8 PM last night? *

Do they have any food restrictions? *

Has your pet had any medication recently? *

Do you have any time constraints for the day? *

Agreement that pick-up will be no earlier than 4:00 and discharge time will be set up once the procedure is complete. *

I read and agree

The estimated cost of these procedures is ($)

Today's Date *

Procedure Consent Form

Client Details

Animal Details

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