Advanced Directive Form Pet Care printable pdf download

Advanced Directive Form Pet Care

Advanced Directive Form

To allow for optimal treatment, all hospitalized Patients are assigned a CPR code which enables us

to carry out your wishes if it should become necessary during or following an emergency or

surgical procedure. In the event that my pet arrests (stops breathing or their heart stops) while at

Fort Thomas Animal Hospital, I authorize the following level of CPR (please initial your choice in

the box):

Do Not Resuscitate (or DNR)

I understand that if my pet stops breathing and/or his/her heart stops beating, Fort

Thomas Animal Hospital will not attempt resuscitation or any further life saving measures.

Normal CPR – involving chest compressions, oxygen therapy and medications

such as epinephrine, atropine, etc.

Having requested such emergency procedures, I agree to be held responsible for a

minimum resuscitation fee of $200.00 to pay for the services performed while staff

members pursue treatment and try to reach me for further directions. I agree to pay this

fee in addition to fees already incurred or for other non-emergency services that may be

performed in the event that my pet survives. I also agree that if the Fort Thomas Animal

Hospital staff is unable to reach me within 15 minutes after the initiation of CPR

procedures, and after a veterinarian determines that further resuscitation efforts are not

warranted, CPR procedures will cease.

Patient’s Name: _____________________ Owner’s Name (print): ____________________________________

Owner’s signature: _________________________________________________ Date: _________________________

Advanced Directive Form Pet Care