Home » Forms » CPR/DNR Authorization

CPR/DNR Authorization

"*" indicates required fields

Client Information

First Name*

Last Name*

Phone*

Address*

Street Address

Address Line 2

City

State

ZIP Code

Pet Information

Pet's Name*

Species*

Cat

Dog

Breed*

Sex*

Male

Neutered Male

Female

Spayed Female

Color*

We will attempt to reach you immediately in the event of an emergency at the phone numbers you have provided.

Please choose ONE of the following emergency resuscitation level options for your pet so we can honor your wishes in the unlikely event of an emergency:*

CPR – I give my full permission to perform all necessary CPR and emergency resuscitation procedures, medications/injections and treatments in an effort to stabilize my pet and accept all incurred cost that could start at $500 and increase without notice.

DNR (Do Not Resuscitate) – Do NOT perform any invasive or aggressive resuscitation measures, allow my pet to pass naturally and without medical intervention.

If you refuse to sign this authorization form then we will not performing any invasive or aggressive resuscitation measures.

Signature*

Date

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

CPR/DNR Authorization

Client Information

Pet Information

Get in touch

Business Hours