Date(Required)

Owner Information

Owner’s Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Emergency Phone(Required)

Email(Required)

Proxy Information

Proxy Name(Required)

First Last

Relationship to Owner

Phone(Required)

Emergency Phone(Required)

Pet Information

Name

Age

Breed

Sex

Male

Female

Spayed/Neutered

Yes

Other pets at home

Primary Care Veterinarian

Phone

Referring Veterinarian

Phone

Resuscitation Directive:

Cardio-pulmonary resuscitation (CPR) is a difficult subject for many people, but one that is very important to review. Emergency cases treated at BPAH must have a resuscitation directive. We are requesting that you choose whether or not you want us to perform lifesaving procedures on your pet in the unlikely event that your pet experiences respiratory and/or cardiac arrest.

We will be able to initiate our efforts without delay. Once we have initiated CPR, we will inform you to make further decisions. Prior to making this decision, please consider the fact that animals that have been successfully resuscitated are extremely critical and unstable. The likelihood of re-arrest is high.

Management of a pet after successful initial resuscitation requires vigilant monitoring for 24 to 48 hours. Once we stabilize your pet, transfer will be arranged to another animal hospital or 24 hour facility.

Please choose from the following options and initial appropriate box.

Attempt Resuscitation: This choice indicates that you authorize all efforts and procedures determined to be appropriate by the veterinarian to try to resuscitate your pet. CPR is more likely to be successful in a previously healthy, young patient and specific recommendations may be made based on your pet’s condition. If CPR is effective, there are often problems that need to be addressed after resuscitation. CPR does not resolve any underlying diseases. It is important that you know the cost of the CPR starts at $400 and the total will vary depending on your animal’s needs. This and the cost of any additional care after the CPR are in addition to your current estimate.

Do Not Resuscitate: Every attempt will be made to prevent a cardiac and/or respiratory arrest from occurring, but if your animal arrests, no CPR will be performed. This option is always an acceptable choice based upon your beliefs and needs.

I have read and understand the CPR options above and in the event my pet experiences respiratory and/or cardiac arrest. I (we) authorize BPAH to act according to my choice above and to begin necessary measures for treatment immediately upon arrival.

Pet Name

Owner’s Name(Required)

First Last

Date(Required)

Proxy Name(Required)

First Last

Date(Required)

Name

First Last

Untitled

Date

DEPOSIT:

$500 deposit to cover lifesaving emergency currently underway to stabilize your pet. This deposit will be applied against the final costs of care.

We will keep a copy of your credit card and your driver’s license on file in order to process emergency care charges in your absence.

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