Consent and Authorization for avian medical and/or surgical procedures
I hereby authorize the performance of the following medical and/or surgical procedures by completing this form.
What procedure/surgery is your pet being admitted for today
What is the best number to reach you during and after the procedure
Is your bird flighted
When is the last time your pet ate
Have they been eating normally
Did you bring their own food
If not, what brand/type do they eat
How does your pet normally consume water (bowl, bottle, etc...)
Did you bring your own cage
Do you normally cover your bird's cage at night
Has your bird been having normal droppings
Has your bird had any regurgitation
Does your bird lay eggs
If so, when was the last clutch and how many eggs were in it
Please list the medication that your pet is currently taking
What time was the last dose given
Do you need any refills? If so, please describe and include syringe feeding formulas
Do you authorize us to do bloodwork
Election of CPR vs DNR
Cardiopulmonary Resuscitation versus Do Not Resuscitate
CPR: I request that in the event of a situation where my pet begins to experience cardiac and/or pulmonary arrest, that the doctors and the staff immediately begin to perform resuscitation CPR efforts. I acknowledge that I will be responsible for any additional fees for these resuscitation attempts, which are incurred above any other estimates given.
DNR: I request that in the event of a situation where my pet begins to experience cardiac and/or pulmonary arrest, that the doctors and the staff do not attempt any resuscitation CPR efforts.
Any other concerns/questions
By typing my name below I certify that I am the owner or authorized agent for the owner of the pet described above. I hereby acknowledge that the process of obtaining my signature on the separate Signature concern Form does not invalidate or alter my agreement and acceptance of the above document and/or the Signature Concern form.
Should be Empty: