PetForward Hospitalization Consent Form

Pet Name:

Owner Name:

Best contact name and number for today:

**It is very important that we are able to reach you. Please have this phone with you and on.

Alternate contact number for today:

CONSENT TO TREAT - please INITIAL each box

I understand that my pet must be picked up at the arranged time, at the latest. We do not staff overnight therefore no pets are able to spend the night with us alone.

Please Initial

I understand that PetForward Urgent Care does not extend credit and agree to pay this account in full at the time of services rendered. A deposit will be required.

Please Initial

I understand that the contact person(s) listed above will be responsible for making medical and financial decisions for my pet and family.

Please Initial

I understand that despite our treatments today, additional diagnostics, treatments and follow-ups may still be needed for my pet.

Please Initial

RESUSCITATION AUTHORIZATION

Definitions:

CPR - Cardiopulmonary resuscitation. This is the treatment for a pet without a heartbeat or not breathing and involves chest compressions, intubation, and manual ventilation to provide oxygen to the pet. CPR efforts are not guaranteed to revive a patient, and if they are successful, that pet has a high change of another arrest event within the next 4 hours which would require additional care and monitoring at a 24-hour facility.

DNR - Do not resuscitate. If this is selected, resuscitation efforts will not be made, and the pet will die if cardiac or respiratory arrest occurs.

In the event of an unexpected life-threatening emergency, I hereby request PetForward Urgent Care to perform... (please initial one)

CPR: I understand that CPR will be attempted but a positive outcome is not guaranteed. I agree to pay additional charges associated, even if above the estimate provided.DNR: I understand that CPR will not be performed, and that death is imminent.

I HAVE READ THE FOREGOING, UNDERSTAND WHAT IT SAYS, AND AGREE.

Owner or Responsible Party Signature

Date

HOSPITALIZATION CONSENT FORM