Consent for Medical Treatment & CPR Directive Form

Save time in the office by filling out your forms online!

Consent for Medical Treatment & CPR Directive Form

"*" indicates required fields

Pet Information

Contact Information

Owner's Name*

In the unlikely event that your pet will require emergency medical treatment while in our care, please read the following directive and choose from the options below. Animal Hospital of Shawnee Hills pledges to give appropriate care to all pets admitted to our care. Should an urgent medical problem arise during your pet’s stay, we will make every effort to contact you to notify you of your pet’s status and to give an estimate of treatment. If your pet’s condition is deemed to be of an urgent nature that will worsen without treatment, supportive treatment will be performed and the charges incurred to your account.

An emergency may consist of, but not limited to the following-seizure, acute collapse, vomiting, diarrhea, allergic reaction (anaphylaxis), cuts/scratches/punctures (bite wounds with same-family pets housed insame kennel), diabetic emergency, or cardiac arrest.

Statement of Best Care: AHSH pledges to provide only the best care to patients for whom we are responsible. Our Veterinarians will perform measures to stabilize your pet in order to eliminate and/or minimize any suffering your pet may endure. By initialing this statement of best care, I understand that these measures will be performed and will be at an additional cost to the estimate I have been provided.

Regardless of my CPR selection below, I understand the following: (please initial)
Please Initial
Please Initial

If stabilizing my pet requires emergency resuscitation measures (CPR)please do the following:

Level 1: Do not perform CPR on my pet. I decline CPR for my pet. I do not wish for any treatment to be performed beyond that required to minimize my pet’s suffering.

Level 2: Perform CPR by placing an endotracheal tube for positive pressure respiration, administer emergency drugs, place an IV catheter for fluid support and drug administration, external cardiac massage (chest compressions). Fee range $150-$300. Treat my pet as the Veterinarian sees fit beyond CPR.

I choose the following option for CPR

If my pet is stabilized by the staff as indicated above, but requires additional specialty care, please take the following steps for my pet’s care:

Option 1: If my pet requires specialty care, and I cannot be reached, please transfer my pet to a veterinary emergency facility. (Transport fees will apply along with any medical care provided prior to transport.)Transfer to the facility where theVeterinarian sees fit (OSU or MedVet).

Option 2: If my pet requires specialty care, and I cannot be reached, I do not wish my pet to be transferred to an emergency specialty facility. I decline additional care above and beyond that provided by Animal Hospital of Shawnee Hills.

I choose the following option for specialty care transfer

In the event that your pet will require non-life-threatening medical care, please read the following directive and choose from the options below.

Example: A non-life-threatening event may consist of, but not limited to, an ear infection, blood in urine/suspected urinary tract infection, eye infection, ruptured cyst, or broken toenail.

Option 1: If I cannot be reached by phone, please treat my pet as the Veterinarian sees fit should a non-life-threatening event occur. I understand that additional costs will be incurred.

Option 2: If I cannot be reached by phone, I do not wish for my pet to be treated for a non-life-threatening condition. I accept that if hospital staff is unable reach me within 24 hours, and my pet is in pain or condition will worsen without treatment, minimal supportive treatment will be performed to ensure my pet is comfortable. I understand that additional costs will be incurred.

I choose the following option for a non-life-threatening medical event care

Release of Legal Liability

I hereby waive, release and discharge any claims for damage that I may have individually or on behalf of my pet, including but not limited to claims for death, injury, or property damage, whether or not resulting from the acts of Animal Hospital or ShawneeHills, its Veterinarians and staff, or that may subsequently accrue as a result of honoring this directive.I have been informed of the fees to pursue the course of treatment recommended for my pet will be in addition to the original estimate and I agree to pay these additional fees regardless of his/her survival. I have read the above information and release. I agree to the above terms and have made my choices for medical care on my pet above.
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.