Owner's Name(s) *
Additional Owner's Name(s)
Must be over 18yrs old and will be listed on account as an additional decision maker.
* Home Phone * Cell Phone Work Phone Can we reach you by text? * Yes No Have you ever brought any animals/pets to Como Park Animal Hospital or AfterHours Veterinary Care before? * Yes No Please list the name of your primary veterinary care clinic. *
Primary Veterinary Clinic
We will forward records from this visit to your primary veterinary clinic listed here, unless you ask us not to.
Do we have your consent to forward records from this visit to your primary veterinary care clinic? * YES - Please forward records from this visit to my primary veterinary clinic. NO - Please do not forward records from this visit to my primary veterinary clinic. How did you hear about us? Friend/Family Client Drive-by Google Social Media Other Name of Patient *
Patient Sex * Male Female Male/Neutered Female/Spayed Unknown Species * Breed * Age / Date of Birth * Color(s) / Markings * Do you have other pets in the house? * Yes No Please list the species of your other pets. * Please list other past or current Veterinary providers. * What is the reason for this visit? * Explanation of CPR services * I have read and understood the information provided below.
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.
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. NO - I do NOT want CPR performed on my pet and elect for DNR.
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 * I agree.
I verify that all information contained in this document is correct and current. I will notify Como Park Animal Hospital of any changes to my contact or ownership information. I authorize that I am the owner of this patient, that I am at least 18 years of age and that I have the authority to authorize medical care for this pet - surgery, diagnostics, treatments, and euthanasia – to be performed by Como Park Animal Hospital, or AfterHours Veterinary Care on their behalf.
I realize that I am financially responsible for decisions made by the above individuals on behalf of my pet and hold the doctors, staff, and agents of AfterHours Veterinary Care hospital harmless in the event that they make a decision that I may disagree with. Medical Records Release * I agree.
I give consent to release medical records for this patient. We will still ask for verbal authorization and a reason for transfer of records. This is for protection of your privacy and security of legal medical information.
Payment for all services are due at time of services performed. * I agree.
I understand that I am financially responsible for all services rendered. A deposit may be required for certain medical or surgical procedures. The hospital accepts payment by Cash, Tele-Check, Visa, MasterCard, Discover, American Express, CareCredit, and Scratchpay. A $35.00 service fee will be applied to all returned checks. Balances over thirty days will be subject to interest at the rate of 1.5% per month. I understand that if the balance is not paid in a timely fashion, I will be responsible not only for the balance due, but any collection agency fees, court costs, and/or attorney fees that are incurred in the attempt to collect this debt.
Legal Responsibility * I agree.
By signing below I assume full legal and financial responsibility for the above listed pet.
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.