DNR Form

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Please fill out the following form before your scheduled appointment.

Client's Name *

First

Last

Pets Name *

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Species *

Breed *

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Gender *

Date of Birth *

Authorization for Treatment in the Event of a Life Threatening Emergency

In the event my pet experiences a cardiac, respiratory or other life-threatening emergency that requires resuscitative or other urgent measures, such as cardiopulmonary resuscitation (CPR), positive pressure ventilation, emergency drugs, or other similar measures, I request that the Veterinarians and/or staff at Cobb Vet Clinic pursue such medical care as indicated below.

Please initial ONE of the directives listed below: *

Resuscitate (R): I authorize emergency treatment if the situation arises (including cardiopulmonary resuscitation (CPR) and other life-saving treatments) and understand this may result in additional charges and I agree to pay for these emergency and life-stabilizing treatments even if they exceed any estimate I may have been provided.
Do Not Resuscitate (DNR): I do NOT authorize emergency treatment if the situation arises (including cardiopulmonary resuscitation (CPR) and other life-saving treatments) and prefer to be contacted before any additional treatment is performed.

I understand *

I understand that despite the best efforts of the veterinarians and staff at Cobb Veterinary Clinic, any emergency treatment, including CPR does not guarantee or assure a favorable outcome for my pet.

Phone Numbers where you can be reached today

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Mobile *

Work

Other

I hereby *

I hereby certify that I am the Owner or Responsible Agent of the patient identified above and that I have read and understand this authorization, including any risks associated with the treatment and care of my animal.

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Print Name *

Date

Signature *

Witness Signature

(Must be 18 years of age or older)

THANK YOU FOR TRUSTING US WITH YOUR PET’S CARE.

DNR Form

DNRForm

Authorization for Treatment in the Event of a Life Threatening Emergency

Phone Numbers where you can be reached today

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