UVH Consent for Intensive Care Hospitalization

1
Pet's Name* This field is required.
2
Owner Information* This field is required.
First Name
Last Name
Phone Number
Email
Please Select
Please Select
Call phone
Text phone
Email
Will not be available via phone or email, contact emergency contact
How would you like to receive daily updates from the doctor?
Please Select
Please Select
Call phone
Text phone
Email
Will not be available via phone or email, contact emergency contact
Our overnight nurses will be sending evening updates. How would you like to receive those?
3
Emergency Contact* This field is required.
First Name
Last Name
Emergency Contact Phone Number
Please Select
Please Select
Yes
No
Is this person authorized to make medical decisions on your behalf in the event we are not able to reach you?
4
In the event that your pet should decline medically and needs immediate action:* This field is required.
YES - You approve treatments and diagnostics if we can not reach you. Up to $400.
NO - You do not approve treatments and diagnostics.
5
If it becomes necessary during your pet's visit, do you want us to administer CPR?* This field is required.
YES - CPR - Should my pet require cardiopulmonary resuscitation (CPR), including cardiac compression, positive pressure respiration, emergency drugs or other heroic interventions, I authorize that the doctors at this hospital provide such medical care and accept responsibility of related charges.
NO - DNR - In the event that my pet's heart and or breathing should stop requiring cardiopulmonary resuscitation (CPR), I decline any and all emergency intervention. Do Not Resuscitate (DNR).
6
Special Care InstructionsSuch as leash walks only, carry up stairs, feed separate from house mate, chews blankets, any verbal commands we should know, etc.
7
Belongings - are you bringing personal items from home?We provide clean fleece blankets as often as they need changing, minimum daily. Please note there is limited space for bedding and belongings from home. Please list, describe, and label all items that will be coming with your pet. Ex. green fuzzy blanket, round bed, tan carrier, black 4' leash, or orange collar.
8
E-Signature* This field is required.
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