Surgical Consent Form (Page 3 of 3) in pdf

Owner Information and Consent for CPR or DNR

Owner’s Name:___________________________

Pet’s Name____________________

Although all types of anesthesia involve some risk regardless of patient age, major side effects and

complications from anesthesia are uncommon. Your pet’s specific risk depends on his/her health, the

type of anesthesia used, and your pet’s response to anesthesia.

All patients of Animal Clinic of Council Bluffs are monitored during surgery with an ECG machine,

pulse oximeter, and a blood pressure machine. In addition to the monitoring equipment, all surgeries

are manually monitored by a doctor or a dedicated technician anesthetist during the procedure.

CPR is the resuscitation of an animal that has stopped breathing or has stopped breathing and whose

heart is not beating.

DNR means “do not resuscitate”. This is a decision that CPR is not to be performed in the event that

the pet stops breathing or has no heartbeat. If you chose DNR and your pet stops breathing or his/her

heart stops beating then we will not attempt to revive your pet and your pet will pass away.

Animals that have survived cardiopulmonary arrest and have been successfully resuscitated (CPR) are

extremely critical and unstable. Management of the post-arrest patient requires vigilant monitoring and

the technical expertise of dedicated critical care personnel. This care is costly and the outcome is

uncertain.

I understand that there are risks associated with anesthesia and I understand no guarantee of successful

treatment can be made. I am the owner or authorized agent of the above named pet and I understand I

am responsible for all fees associated with procedures preformed on the pet no matter the outcome.

I HAVE READ AND UNDERSTOOD THE INFORMATION ABOVE OR HAVE HAD IT

EXPLAINED TO MY SATISFACTION. I agree to indemnify Dr. Harrer and the staff at Animal

Clinic of Council Bluffs, its servants or agents from any loss or liability which they may incur as a

result of an inaccuracy whether intended or otherwise in this my solemn declaration.

Signed __________________________________________ Date ____________________________

I wish the staff to perform CPR (resuscitation) on my pet if my pet suffers from cardiac or respiratory

arrest. My pet may not respond to CPR or may respond initially and then suffer another arrest later. My pet may

die despite CPR. The estimate for initial CPR is $300 to $500.

Signed ____________________________________

I DO NOT want CPR performed on my pet. I understand that if my pet stops breathing and/or his/her

heart stops beating that my pet will pass away unless CPR is performed. I elect to have DNR orders placed on

my pet’s record OR I elect that the veterinary staff stop the initial attempts at CPR that may have been started

while I was being informed of the condition of my pet and my options.

Signed _____________________________________

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Surgical Consent Form Page 3