Surgical Admission CPR Form

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

Surgical Admission CPR

"*" indicates required fields

In the unlikely event that your pet will require resuscitative measures, please read the following directive and choose one of the options for cardiopulmonary resuscitation (CPR).

I have been informed that during anesthesia, life threatening complications such as respiratory and/or cardiac arrest may occur; requiring CPR. If my pet stops breathing or his/her heart stops beating, I realize even the most successful CPR measures may not restore him/her to good mental and physical health. In addition to the limited likelihood of success from CPR treatment, I understand that such care requires that I pay additional fees. By initialing one of the following choices, I request:

  • Level 1: NO CPR procedures are to be administered. DO NOT PERFORM CPR ON MY PET.
  • Level 2: Endotracheal tube intubation, positive pressure respiration, administration of emergency drugs, external cardiac massage (chest compressions). Fee range to $150-$300.

Please select one:*

I accept that if hospital staff members are unable to reach me within twenty (20) minutes after the initiation of CPR and after administering reasonable treatment there appears to be virtually no hope for medical success, CPR will be withdrawn. I have been informed that 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.

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 Shawnee Hills, 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.

Pet Owner Name:*
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.