Boarding Admission and Consent Form Owner's Name(s) * First Name Last Name Pet's Name * Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Primary Phone * (###) ### #### Additional Phone Please list name and number (###) ### #### Can we reach you by text? * Yes No How do we reach you while away? * Emergency Contact Name * First Name Last Name Emergency Contact Phone Number * (###) ### #### Begin Boarding Date * You must call to make an appointment. Submitting this form does not add you to the schedule. MM DD YYYY End Boarding Date * MM DD YYYY Anticipated Pickup Time * Hour Minute Second AM PM Current Health Concerns/Alerts * Medications * Medication Amount/Frequency * Feeding Instructions (Type/Amount/Frequency) * Additional Instructions/Requests * If deemed appropriate by a veterinarian, do we have your consent to sedate your pet? * Yes No Please list & describe all items brought. CPAH is not responsible for items lost or damaged while here. * Leash/Collar Toys Food/Treats ( Medications Describe Leash/Collar * Describe Toys * Describe Food/Treats * Describe Medications * Services requested during your pet's stay: * Bath (Baths are given near the end of a pet's stay and may impact pickup time) Nail Trim Anal Gland Expression Other Please specify other service requests. Explanation of CPR services * CPR is the resuscitation of an animal that has stopped breathing or has stopped breathing and whose heart is not beating. Resuscitation of an animal that has stopped breathing but still has a heartbeat is more likely to succeed than resuscitation of an animal with no breathing and no heartbeat. 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 die. Animals that have survived cardiopulmonary arrest and have been successfully resuscitated (CPR) are extremely critical and unstable. Survival of respiratory arrest in which the heart has continued to beat carries a slightly better prognosis. The likelihood of re-arrest is high and usually occurs within 4 hours of the initial arrest. This means that there is only about a 20% chance that your pet will stay alive for the first 4 hours after resuscitation. Long term survival is even more grave and may be as low as 1%. 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 have read and understood the information provided. If deemed appropriate by a veterinarian, do we have your consent to perform CPR on your pet? * YES - 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. The estimate for the first 24 to 48 hours of veterinary care after CPR depends partially on pre-existing injury or illness and may be $1500 to $3500. Costs can greatly exceed this estimate. NO - I do NOT want CPR performed on my pet and elect for DNR. I understand that if my pet stops breathing and/or his/her heart stops beating that my pet will likely die. 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. Authorization and consent for services * My signature below certifies that all I am an authorized owner or agent for this pet, I have read and understand all the terms listed on the form titled Boarding Agreement & Consent (v.2) that was provided to me, and have given full and truthful information relating to any health conditions, special requests or needs for my pet. I assume full responsibility for services requested above and treatment expenses for medical conditions that arise while my pet is boarding. I agree. Legal Responsibility * By signing below I assume full legal and financial responsibility for the above listed pet. I agree. Electronic Signature * By selecting the "Submit" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form. I agree to the privacy policy. Thank you!
