Emergency Vet Services Form printable pdf download

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:

Emergency Vet Services Form