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Procedure Intake Form

Keith Blass, DVM, DACVIM (Cardiology)

Jacqueline Gest, DVM, DACVIM (Internal Medicine)

Ariel Kravitz, DVM, DACVS- SA, CVA (Surgery)

Carol Margolis, DVM, DACT (Theriogenology)

Victoria Kearns, LVT, CCRP, NCM, OACM (Rehab)

Riley Palmese, LVT, CCAT (Rehab)

Owner Name:

Address:

Client Phone Number:

Pet's Name :

Patient ID:

Species:

Breed:

Sex:

Age:

Color:

Weight:

Primary Contact Person & Phone #:

Emergency Person & Phone #:

When was the last time the patient ate?

Is patient on any medications?

Yes

If so, please list the names, doses and last time given?

What is the patient here for and any special instructions?

*I have discussed to my satisfaction the health status of my pet listed
above with Gold Coast Center for Veterinary Care.

*I understand in the event my pet’s heart and/or breathing stops (cardiopulmonary arrest), resuscitation efforts according to the advanced directive authorized below will be undertaken by the doctor(s) and/or staff of Gold Coast Center for Veterinary Care.

*I understand the doctor(s) and/or staff will immediately attempt to contact me via telephone at the telephone number(s) provided by me in the event of cardiac and/or respiratory arrest of my pet.

I request the following resuscitation effort(s) be implemented immediately by the doctor(s) and staff of Gold Coast Center for Veterinary Care

(CHOOSE ONE):

Untitled multiple choice field

DO NOT RESUSCITATE (DNR) In the event my pet’s heart and/or breathing stops, I request no person shall attempt to resuscitate my pet.

CLOSED-CHEST CARDIOPULMONARY RESUSCITATION (BLS) I request the doctor(s) and staff attempts to resuscitate my pet through utilization of artificial respiration and/or heart compression, as well as administration of various emergency medications and/or fluids as deemed necessary and/or appropriate by the attending veterinarian.

I voluntarily execute this order for my pet listed above and I understand its full import. I hereby authorize performance of the above medical/surgical procedure. The nature of such service has been described to me to my satisfaction and I realize that no guarantee and no warranty can ethically or professionally be made regarding the results or cure.

I understand that I assume financial responsibility for all services rendered, and that payment is due upon hospital discharge of the patient name.

Signature of Owner or Authorized Agent:

Signature