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Emergency Client Intake Form and CPR Directive
Primary Owner Information
Name
(Required)
First
Last
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
(Required)
Email
(Required)
Have you been here before?
(Required)
Yes
No
Do you have pet insurance?
(Required)
Yes
No
If yes, what kind?
How did you hear about us?
(Required)
Billboard
Drive By Location
Facebook/Instagram
Google/Internet Search
My Veterinarian
NextDoor
Friend/Family
Community Event
Grooming/Boarding
If so, who?
If so, which?
Veterinarian Information
Primary Care Veterinary Hospital
(Required)
Primary Veterinarian
(Required)
Referring Veterinary Hospital (If Different Than Primary)
Secondary Owner Information (Secondary Authorization for Medical Decisions)
Name
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
Email
Relationship
Patient Information
Name
(Required)
Species
(Required)
Breed
Age/DOB
(Required)
Sex
(Required)
M
F
Unknown
Neutered/Spayed
(Required)
Yes
No
Color
Last Known Rabies Vaccination
MM slash DD slash YYYY
Diet
(Required)
Travel History
Drug Allergies or Vaccine Reactions
(Required)
Reason For Visit
(Required)
Medical History
(Required)
Current Medications (tablet size/concentration, dose, frequency)
Add
Remove
Cardiopulmonary Resuscitation (CPR) Directive
Date
(Required)
MM slash DD slash YYYY
Consent
(Required)
In order to act in yours and your pet’s best interest, we request a proactive decision regarding Cardiopulmonary Resuscitation (CPR) status. Our teams are open to discussing this uncomfortable but important decision with you regarding your beloved pet should you need clarification. The documented overall success rate of CPR in dog and cat species is low (<10%). Unfortunately, there is insufficient data available regarding the success rates of CPR in exotic companion pet patients, however, based on our experiences alongside this limited literature, successful CPR outcomes in exotic patients are even lower. We believe it is our obligation to immediately provide basic life support so that we can focus on meeting the needs of your pet, prior to contacting you. The cost of CPR can be more than $1000 depending on how complicated the circumstances are. The doctor oversees the type and degree of intervention as it is highly case and species dependent.
I am the owner/agent of this pet and AUTHORIZE CPR efforts and accept financial responsibility
I am the owner/agent of this pet and request DO NOT RESUSCITATE (DNR)
