Animal Center for Emergency and Specialty logo
Contact Us

See you at The Czar’s Promise Walk on Oct 12!

CPR Authorization Form

Save time at your first appointment! Complete your required CPR authorization form online before your visit.

Get started

CPR authorization form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

CPR Authorization

Client Name(Required)
MM slash DD slash YYYY
CPR Authorization(Required)
DNR (Do Not Resuscitate)
In the event of cardiopulmonary arrest, I do not want any resuscitative efforts performed on my pet. I request that my pet be allowed to pass without intervention. I will be notified of an arrest event as soon as possible. If needed, some interventions may be provided to my pet to allow for a peaceful passing, including oxygen, pain medications or sedation. This may cost anywhere from $50-$300.

CPR (Cardiopulmonary resuscitation)
In the event of cardiopulmonary arrest, I request that resuscitative efforts be performed on my pet. This includes external compressions, intubation or creation of a surgical airway, oxygen/ventilatory support, injectable medications, monitoring, defibrillation, and fluids. Internal CPR is the best form of CPR for large dogs, dogs already in surgery or dogs with fluid in their chest as a presenting concern (pleural or pericardial effusion). Performing intrathoracic CPR means that we make an incision through the chest wall (or diaphragm during surgery). This form of CPR does increase the chance of resuscitation if deemed appropriate (not appropriate for cats or small dogs). Your veterinarian will determine the best CPR for your pet. The cost of CPR may range from $250 to $1000. This does not include the cost of post-arrest monitoring and care.
CPR/DNR(Required)
Clear Signature