am the owner (or agent of the owner) of,
I authorize and request you to hospitalize this animal for purposes of diagnosis, treatment, surgery, dental, or other procedures, as specified by this release and approve the use of whatever anesthetics you deem advisable for the well-being of the animal. I understand that you will use reasonable precautions to assure the animal’s safety while it is in your care but will not hold you responsible if it should injure itself, escape, fail to eat, become ill, or die. I absolve you of all liability arising from the performance of procedures requested herein. I understand the anesthetic and surgical, diagnostic, or therapeutic procedures may involve risk of complications, injury, or even death, from both known and unknown causes and no warranty or guarantee has been either expressed or implied as to result or cure. Furthermore, I authorize the hospital staff in an emergency situation, to follow through with such procedures as are necessary from the well-being of my pet on a continuing basis until further communication with me. I agree to assume financial responsibility for all routine and emergency services rendered.
I understand that prior to my pet’s procedure, a pre-anesthetic examination and bloodwork are performed to screen for any potential pre-existing condition which might complicate the anesthetic event. Electrocardiograms are performed on dogs prior to anesthesia. I accept responsibility for the charge associated with these necessary procedures.
Please indicate if you would like to have any of the following services performed while your pet is under anesthesia:
So that we may register your pet, please provide the following information:
*Please ensure the alternate contact is someone other than yourself
FOR PETS UNDER THE AGE OF 12 MONTHS
CPR or DNR Consent
CPR means Cardio Pulmonary Resuscitation and is the treatment or resuscitation of a pet who has stopped breathing or whose heart has stopped beating. Resuscitation of a pet who has stopped breathing but still has a heartbeat is more likely to succeed than resuscitation of a pet with no heartbeat.
DNR means Do Not Resuscitate. This means if a pet stops breathing or the heart stops, no effort will be made to attempt to revive the pet, and the pet will die.
IF YOUR PET IS SCHEDULED FOR A DENTAL PROCEDURE, PLEASE READ AND INITIAL BELOW:
I acknowledge that if I cannot be reached during a dental procedure, I authorize any necessary procedures. These may include dental radiographs, extractions, minor oral surgery, or gingival biopsy.
Your signature below constitutes your acknowledgment, as the owner or the owner’s agent, that you have read and agreed to the above, that the procedure(s) have been explained to your satisfaction, and that you authorize and consent to the performance of the procedure(s) and to the administration of anesthesia.