Authorization for Non-Surgical Procedure Form Authorization for Non-Surgical Procedure Owner's Name * Owner's Name First First Last Last Pet's Name * Phone Number * Email * Preferred method of contact for updates * Email Call Text Presenting Complaint Authorized procedure(s) to be performed Medical History Is your pet eating/drinking normally? * Yes No Did your pet eat this morning? * Yes No Please describe What brand of food and how much do you feed? Is there any changes in urination/defecation? * Yes No Any vomiting/regurgitation? * Yes No Please explain Please explain Respiratory concerns (coughing, sneezing, trouble breathing)? * Yes No Changes is attitude/energy level/behavior? * Yes No Please explain Please explain Please list current medications (including supplements, and preventatives) dosages, and last administration In the event of spontaneous arrest (heart rate, breathing, etc.), I elect the following (please select one) * CPR - Cardiopulmonary resuscitation (CPR) of a collapsed or unconscious patient is tailored to meet the needs of the individual, including but not limited to: IV catheter placement, IV fluids, emergency injectable medications, intubation and artificial ventilation, or chest compressions. (Estimated, but not limited to, $500. Not reflected in any estimate given) DNR - DNR “do not resuscitate”, this means that in the event of cardiac arrest, CPR will NOT be performed if the patient stops breathing, enters cardiac arrest, collapses, and/or becomes unconscious. Please read below and sign I hereby authorize American Animal Hospital to perform such diagnostic, therapeutic and surgical procedures as are, in their opinion, necessary and advisable for treatment and maintenance of my pet’s health and well being. The nature of such services has been described to me to my satisfaction and, while I expect all procedures to be done to the best of the abilities of the professional staff, I realize that no guarantee or warranty can ethically, or professionally, be made regarding the results or cure. I understand that I assume full financial responsibility for all services rendered, regardless of outcome. Signature * signature keyboard Clear Date * Captcha Submit If you are human, leave this field blank.
