Emergency Vet Service Form
CLIENT INFORMATION
Owner’s Name________________________
Spouse/Co-owner_____________________
Address______________________________
City______________ State____ Zip______
Home Phone__________________________
Cell 1_____________ Cell 2____________
*Arrival Date at Wagsworth: _____________ E-mail Address___________________________
Requested Emergency Vet: _______________________________________
PATIENT INFORMATION
Pet’s Name:__________________ Dog / Cat (circle one) Breed________________________
Sex (please circle one): female / spayed female / male / neutered male Date of Birth_________
PRIMARY CARE VETERINARIAN INFORMATION
Veterinarian Name_______________________ Practice Name___________________________
Referring Veterinarian (if different from primary care) _________________________________
Who should we send a referral report? (Circle one) Primary care / referring veterinarian / both
ANESTHESIA AND LIFE SUPPORT CONSENT
Some form of anesthesia and/or sedation is required for all surgical procedures. Precautions are taken for
each patient as an individual when it comes to anesthesia. Your pet will be required to have preliminary
diagnostic tests performed prior to anesthesia/surgery. This may include but not be limited to bloodwork,
radiographs, ultrasound, or cardiology consults. You will be instructed as to what tests may be necessary
for your pet. Anesthesia is a risk for all patients, no matter their age or breed.
All patients being treated are required to have a (CPR) Cardiopulmonary Resuscitation or (DNR) Do Not
Resuscitate code. In all likelihood, we will not need this information. CPR is the resuscitation of an
animal that has stopped breathing or whose heart has stopped. Animals that survive cardiopulmonary
arrest and have been successfully resuscitate (CPR) are EXTREMELY critical and unstable.
Please select ONLY ONE of the following by initialing next to your selection.
________ I DO NOT want CPR performed on my pet. I understand that my pet WILL die in
the event that he/she stops breathing and/or his/her heart stops beating. I have elected to have a
DNR (Do Not Resuscitate) order placed on my pet’s record.
________ I wish the staff to perform CPR (resuscitation) on my pet if my pet suffers from
cardiac or respiratory arrest. Every attempt will be made to resuscitate your pet. I understand
that my pet may not respond to CPR and may die despite CPR. I understand that the cost could
substantially exceed the estimate.
PLEASE READ CAREFULLY AND SIGN BELOW
I am the owner or responsible agent for the animal described above and have the authority to execute this
consent. I am over 18 years of age. I have read and understand the anesthesia and life support policy and
agree. I hereby authorize the use of the appropriate anesthetics and other medication as deemed necessary
by the veterinarian. I also authorize the performance of the above life support. I have had the opportunity
to ask any questions that I may have regarding the anesthesia and life support policies that were given. I
authorize that my credit card information be given to the Emergency Vet at time of drop off.
Signature:
Date: