Inpatient Diagnostic Testing Permission Form

Thank you for choosing Healing Paws Veterinary Care. Rest assured that this form is different and shorter than your recent history form but still incredibly important. These few simple questions will help us know if we need to make any changes in your pet’s current testing, treatment, or vaccination recommendations! If you have any questions, please give us a call. We look forward to seeing you and your pet!

Pet's Name(Required)

Owner Bringing the Pet to the Visit(Required)

First Last

Mobile Phone Number(Required)

Has your pet's condition, health, or behavior changed since the last visit?

Yes

Please tell us more(Required)

Has your pet newly experienced any of the following since their last visit?(Required)

Discomfort or pain

Change in appetite

Vomiting

Diarrhea

Constipation

Dragging their bottom

Itching

Anxiousness/Nervousness

Other

None of the above

Please tell us more(Required)

Is your pet currently taking prescribed medications or eating prescription food?(Required)

Yes

I am trying but they don't take all of their medications

Please list the medications and/or prescription food including how much and what times of day you give them(Required)

Please tell us more about the experience giving them medications so that we can adjust their plan accordingly(Required)

Does your pet receive any over the counter medications, supplements, herbs, or vitamins?

Yes

Please list all of them including how much and what times of day you give them(Required)

Would you like any medication, supplements, dental care products, foods, or parasite preventatives refilled today?(Required)

Yes

Please list all products and how many months supply you would like of each(Required)

Is there any additional information you would like our team to know or any additional services you would like to know if we can provide today?(Required)

Yes

Please tell us more(Required)

Important Authorizations

Authorization to Perform Examination/Diagnostics/Treatment: I hereby authorize the Healing Paws Veterinary Care, Inc. staff and doctor to perform an examination. I understand that the condition my pet has may include them having pain or anxiety and also authorize the Healing Paws Veterinary Care, Inc. staff and doctor to provide short-term pain or anxiety relief to my pet during their stay. At the end of the examination, if the doctor feels that further diagnostic testing is necessary, the tests may be performed during my pet's visit. With the results of those tests, I understand that the doctor will personalize a treatment recommendation for my pet and then will review those recommendations with myself or my representative. I understand that receiving diagnostic testing and treatments allows my pet to feel more comfortable as soon as possible and allows the doctor to evaluate their results and treatments so that I can receive the most accurate treatment recommendation plan. I also understand that if live fleas, flea larva, or flea dirt is found on my pet, they will be administered a medical flea and tick preventative while at Healing Paws Veterinary Care, and I will be responsible for the cost of that product.(Required)

I have read and understand this authorization and hereby accept and agree to the terms of the consent for examination pain or relaxing medication treatment as described above. I authorize the doctor and staff of Healing Paws Veterinary Care, Inc. permission to perform examination, tests, and treatments on my pet today and am responsible for the payment of these services. I understand that I will be contacted for further permission if the total of the examination, in-patient care, tests and treatments for my pets is over the cost of my signed treatment plan today.

CPR/DNR Consent

It is extremely important that you are reachable by phone the day of the procedure. In the case of medical emergencies and unexpected treatment decision making, the doctor will need your permission and time is critical both during medical emergencies. In the unlikely event that the above-named pet should experience cardiac or respiratory arrest while being hospitalized today, we need to know, in advance, what your wishes are for your pet. If your pet does experience anesthetic difficulty, cardiac or respiratory arrest, we will absolutely contact you. However, your pet's safety and well-being come first, so we need you to direct us here as to your wishes for their care.

Cardiopulmonary Resuscitation (CPR):

All resuscitative efforts are to be attempted to restore normal heart function and to breathe as deemed necessary by the doctor until I can be reached. Should my pet require cardiopulmonary resuscitation (CPR), I request that the doctor(s) pursues medical care. I understand that this is a cost in ADDITION to any estimate, and I agree to pay this fee. The cost of full CPR is typically at least an additional $300 or more and in no way guarantees that my pet will survive their cardiac or respiratory event. Patients who require CPR typically need at least 24 to 48 hours of intensive care and monitoring at a specialty facility following resuscitation. It will be necessary for me to transport my pet to the specialty facility and I will be responsible for the charges for my pet's care at that facility.

Do Not Attempt Resuscitation (DNR):

No cardiopulmonary resuscitation (CPR) efforts will be performed in effort to save my pet if they have cardiac or respiratory arrest, only the administration of medication to help ease my pet's passing may be used.

Please select the option you'd like the doctors to proceed with.(Required)

I agree to CPR being performed in case of arrest. However, if CPR has been performed for 30 minutes, I have not been able to yet be reached by either phone number listed above, and my pet is unable to support cardiac or respiratory function on their own, I authorize the doctor on duty to make the decision to discontinue CPR which may result in my pet's death.

I elect a “Do Not Resuscitate” status in case of arrest. If my pet is actively suffering during its cardiac and/or respiratory arrest, the doctor may give a euthanasia solution to ease its passing.

I elect a “Do Not Resuscitate” status in case of arrest. The doctor does not have permission to give my pet euthanasia solution but should remove airway support if they are experiencing cardiac or respiratory arrest.

Information About Veterinary Medical Care:

I realize that no guarantee or warranty can ethically or professionally be made regarding outcomes of treatment of medical illnesses or effectiveness of preventative care products and procedures. I have been informed that there are certain risks and complications associated with disease, sedation, anesthesia, and/or any operation/procedure and that while the team at Healing Paws Veterinary Care, Inc has my pet's best interest in mind at all times, sometimes complications occur. I further understand that during the course of the examination, diagnostics, procedures, or treatments, unforeseen conditions may arise that may necessitate the performance of additional procedures deemed necessary by the veterinarian. I am encouraged to discuss any concerns I have about these risks with the attending veterinarian before treatment or diagnostics are initiated. I am aware that the practice of veterinary medicine is not an exact science and, thus, there are no guarantees for successful treatment. I have been encouraged and given the opportunity to discuss any questions I may have regarding my pet's medical care. I accept that my financial obligations remain regardless of the outcome of treatment.

I am the owner or the authorized agent for the owner of the animal described above, and I have the authority to execute consent for examination, diagnostic testing, procedures, and treatment of said animal. I have read and understand this authorization and hereby accept and agree to the terms of the consent for examination and treatment. I understand that I am financially responsible for any services, products, or treatments provided to my pet and that I can request a treatment plan and cost estimate for my pet at the time of my visit.(Required)

I have read and understand

My signature below certifies that I am over eighteen years of age(Required)

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Name

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Inpatient Diagnostic Testing Permission Form

Important Authorizations

CPR/DNR Consent

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