Advanced Directive Form

To allow for optimal treatment, all hospitalized Patients are assigned a CPR code which enables us to carry out your wishes if it should become necessary during or following an emergency or surgical procedure. In the event that my pet arrests (stops breathing or their heart stops) while at Fort Thomas Animal Hospital, I authorize the following level of CPR (please initial your choice in the box):

Owner's Name(Required)

First Last

Pet's Name(Required)

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Do Not Resuscitate (or DNR)

Normal CPR – involving chest compressions, oxygen therapy and medications such as epinephrine, atropine, etc.

I understand that if my pet stops breathing and/or his/her heart stops beating, Fort Thomas Animal Hospital will not attempt resuscitation or any further life saving measures.

Having requested such emergency procedures, I agree to be held responsible for a minimum resuscitation fee of $200.00 to pay for the services performed while staff members pursue treatment and try to reach me for further directions. I agree to pay this fee in addition to fees already incurred or for other non-emergency services that may be performed in the event that my pet survives. I also agree that if the Fort Thomas Animal Hospital staff is unable to reach me within 15 minutes after the initiation of CPR procedures, and after a veterinarian determines that further resuscitation efforts are not warranted, CPR procedures will cease.

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Advanced Directive Form

Expert Veterinary Care in Fort Thomas, KY