Online Forms

Surgical Check-In Form

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Surgical Check-In Form

Name *

First

Last

Email *

Pet's Name *

Name of Procedure: *

Phone number where authorized agent can be reached while pet is in hospital: *

I consent to receive SMS text messages from Willakenzie Animal Clinic. Msg & data rates may apply. Reply STOP to opt-out. *

Yes
No

Additional phone number where authorized agent can be reached while pet is in hospital:

Standard Risks and Authorization

Date *

Financial Responsibility

Date *

CPR/DNR (Resuscitate or Do Not Resuscitate)

The vast majority of procedures and hospitalizations have good outcomes and proceed according to plan. In the unexpected event of a sudden decline of your pet’s health, we want to be prepared to respond in a manner that meets your wishes and fulfills your emotional and financial needs. CPR/Resuscitation may include establishment of an airway via insertion of an endotracheal tube, IV catheterization, administration of IV fluids, injections of medications, performing chest compressions, or delivery of intracardiac medications. Animals that have survived cardiac arrest and have been successfully resuscitated are extremely critical and unstable. Management of the post arrest patient requires vigilant monitoring and technical expertise and the outcome is uncertain. PLEASE CHOOSE ONE BELOW

CPR/Resuscitate

I consent to all costs incurred during the process of resuscitation of my pet. I understand that I will incur charges beyond those included in my agreed upon estimate. I agree to additional charges up to $500.00 should the CPR process be started prior to contacting me.
I decline CPR in the event that it is deemed necessary for the survival of my pet. I understand that by signing this “Do Not Resuscitate” order on my pet, the medical staff will not perform CPR or give possibly life-saving medications.

Date *

Name

Online Forms

Surgical Check-In Form

Surgical Check-In Form

Standard Risks and Authorization

Financial Responsibility

CPR/DNR (Resuscitate or Do Not Resuscitate)

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