Surgery Consent Form

Consent for Treatment or Surgery and Critical Care Life Support Directive

LifeSupport Directive

All patients treated by this hospital must have a Cardiopulmonary Resuscitation (CPR) or Do Not Resuscitate(DNR) code. Likely, you will not need this information, but as is common practice in human medicine, we would like you to think about how you would like us to proceed in the unlikely event of an emergency. CPR is the resuscitation of an animal that has stopped breathing or whose heart has stopped beating. Animals that survive cardiopulmonary arrest and have been successfully resuscitated (CPR) are highly critical and unstable. The likelihood of re-arrest is HIGH and usually occurs within 4 hours of the initial arrest.

The chances of long term “normal” survival is extremely low and may be as little as 1%.

Management of the post-arrest patient requires vigilant monitoring and the technical expertise of dedicated critical care personnel at a specialty hospital. The care is costly, and the outcome is uncertain.

Please select one of the choices below. If you have additional questions, please ask a staff member.

GREEN - CPR - I wish the staff to perform closed-chest CPR (resuscitation) on my pet if my pet suffers from cardiac or respiratory arrest. I understand that my pet may not respond to CPR and may die despite CPR. I also understand that if my pet responds to CPR, he/she will likely be arrested again. I acknowledge that the initial cost of CPR is $600-800 and that I will transfer my pet to a specialty critical care monitoring hospital that could cost thousands more for necessary aftercare. I understand that the cost could substantially exceed this estimate. I understand payment will be required either during my absence or immediately upon my return. I accept this financial responsibility and agree to pay for all services rendered. I understand that the staff will contact me directly upon the initiation of CPR and if I am not available, will proceed at the discretion and under the direction of the attending veterinarian until I can be reached.

RED - DNR - I DO NOT want CPR performed on my pet. I understand that if my pet suffers from cardiac or respiratory arrest, my pet will die. I have elected to have a DNR (Do Not Resuscitate) order placed on my pet’s record. I understand that even in this unlikely event, payment will be required for services rendered prior to my pet’s arrest. I accept this financial responsibility and agree to pay for all services rendered.

I, the undersigned, am the owner or agent for the owner of the animal described above. I have the full and exclusive authority to execute this consent and am over 18 years of age.

• I give permission to doctors, staff, authorized agents, or representatives of this hospital to hospitalize, anesthetize, medicate, treat, or perform surgery on my pet.
• I am aware of the risks and complications associated with any surgery, anesthesia, hospitalization, procedure, and medications that may be given or dispensed for my pet.
• I further understand that unforeseen conditions may arise that may necessitate additional procedures at an additional cost.
• If life-saving emergency care is required, I authorize this hospital's doctors, staff, authorized agents, or representatives to provide treatment which they deem necessary until I can be reached.
• I authorize the use of appropriate anesthesia and pain relief medication as needed before and after the procedure.
• I understand that if my pet remains hospitalized, there will not be overnight supervision provided.
• I further understand that it can be very stressful to an animal to be hospitalized and this stress may cause underlying physical conditions to become apparent. This can result in illness and even death. While the hospital strives to provide the best in veterinary services; unfortunately, no guarantee can be made regarding the outcome of the services provided.I release the hospital from any and all liabilities.