Owner Name *

First Name

Last Name

Anesthetic Procedures Consent Form *

Please select one:

Do not proceed with additional treatments without reaching me first. (Outside of emergency treatments)

Proceed with additional treatments up to an amount not to exceed $200 (Outside of emergency treatments)

Proceed with additional treatments between $200 and not to exceed $500 (Outside of emergency treatments)

Consent for CPR or DNR *

In the case that your pet was to suffer cardiac and/or pulmonary arrest (heart or breathing stops), do you authorize us to provide Life-saving measures (i.e. cardiopulmonary resuscitation)? Costs of these services can exceed $500 and are NOT reflected in this estimate. If you choose to allow these procedures for your pet, you will be contacted as soon as possible to be informed of the situation and given the options how to proceed.

CPR, I authorize appropriate life saving measures. I understand and assume all financial responsibility for this.

DNR, I do not wish for life saving measures to be employed. I am electing "Do Not Resuscitate" status for my pet.

Authorization *

I verify I am the owner (or Authorized agent for the owner) of the above-named pet and authorize the above procedure to be performed. I authorize the use of anesthesia and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure(s) as directed by the veterinarian. I have been advised as to the nature of this procedure to be performed and the risks involved. I understand also that there is always a risk associated with any anesthesia episode, even in apparently healthy animals and have discussed my concerns with the veterinarian. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgement. I accept responsibility for any result in additional charges. I agree to be responsible for any charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand no staff will be attending to my pet overnight (pets needing special care may be referred to a 24-hour hospital). Please Enter Phone Number:

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Alternative Phone Number

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