Hospital Procedure, Anesthesia & Medical Authorization Release Form

General Information on CPR

Should, based on the medical judgment of a licensed Doctor of Veterinary Medicine, my pet named Bella require cardiopulmonary resuscitation (CPR), including cardiac compression, positive pressure respiration, emergency drugs, or other heroic interventions, I request or decline that the doctor(s) at Appanasha Pet Clinic pursue such medical care as indicated below. I have been informed by Appanasha Pet Clinic that less than 5% of animals that require CPR will survive to be discharged from the hospital. I understand that despite the best efforts of the veterinarians and staff at the Appanasha Pet Clinic, CPR may not save my pet’s life. I also understand that even if CPR is successful that my pet may never regain his/her normal mental and physical health and, thus, may leave him/her unresponsive.

RELEASE OF LEGAL LIABILITY

Regardless of whether I consent or decline to have CPR performed on my pet, in consideration for following my directive, I hereby waive, release and discharge any and all claims for damages, including, but not limited to claims for death, injury or property damage, whether or not resulting from the negligence, misconduct or other acts Appanasha Pet Clinic, its veterinarians and staff, that I may have individually or on behalf of my pet, or that may subsequently accrue, as a result of honoring this directive, and I declare that any such veterinarian, staff and the Appanasha Pet Clinic is acting in accordance with my directions. This is intended to be an advance release of legal liability, even if negligence or other misconduct occurs.

I, the undersigned owner or owner’s agent, of the pet identified above, certify that I am over 18 years of age and hereby authorize the doctor(s) at Appanasha Pet Clinic to perform the above anesthetic and surgical procedure(s) for my pet. I understand that some risk always exists with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. While I accept that all procedures will be done to the best of the abilities of the staff at Appanasha Pet Clinic, I understand that no guarantee or warranty has been made regarding the results that may be achieved.

Owners will receive updated cost estimates whenever additional testing or precautions are necessary at the owner’s request. Appanasha Pet Clinic will also make every effort to contact owner prior to determining or performing any additional treatment that changes the original estimates, outside of emergency care which will be deemed necessary by the veterinarian.

I understand that Appanasha Pet Clinic will make every reasonable effort to contact me prior to performing additional procedures and that if I cannot be reached an additional anesthetic procedure may be required in the future to avoid keeping my pet under anesthesia longer than necessary.