Emergency Vet Services Agreement Client Information First and foremost our number one concern is your pet’s health. We ask that clients with elderly pets fill out our Emergency Vet Service Agreement. If your dog needs emergency vet service we will try to get in contact with you, if you are unavailable we will contact your emergency contact. If you have a preference in which emergency vet we take your dog too please let us know.Preferred Emergency Vet*Owner's Name*Spouse/Co-Owner's NameAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell Phone*Arrival Date at Wagsworth* Date Format: MM slash DD slash YYYY Email* Patient InformationPet's Name*Pet Type*DogCatBreedSex*FemaleSpayed FemaleMaleNeutered MaleDate of Birth Date Format: MM slash DD slash YYYY Relevant Health History of Pet*Previous surgeries, cancer treatment, ongoing issues, etc.Primary Care Veterinarian InformationVeterinarian Name*Practice Name*Referring Veterinarian (if different from primary care)Who should we send a referral report?Primary CareReferring VeterinarianBothAnesthesia & Life Support ConsentSome form of anesthesia and/or sedation is required for all surgical procedures. Precautions are taken for each patient as an individual when it comes to anesthesia. Your pet will be required to have preliminary diagnostic tests performed prior to anesthesia/surgery. This may include but not be limited to bloodwork, radiographs, ultrasound, or cardiology consults. You will be instructed as to what tests may be necessary for your pet. Anesthesia is a risk for all patients, no matter their age or breed. All patients being treated are required to have a (CPR) Cardiopulmonary Resuscitation or (DNR) Do Not Resuscitate code. In all likelihood, we will not need this information. CPR is the resuscitation of an animal that has stopped breathing or whose heart has stopped. Animals that survive cardiopulmonary arrest and have been successfully resuscitate (CPR) are EXTREMELY critical and unstable.Please select ONLY ONE of the following by initialing next to your selection.*I DO NOT want CPR performed on my pet. I understand that my pet WILL die in the event that he/she stops breathing and/or his/her heart stops beating. I have elected to have a DNR (Do Not Resuscitate) order placed on my pet’s record.I wish the staff to perform CPR (resuscitation) on my pet if my pet suffers from cardiac or respiratory arrest. Every attempt will be made to resuscitate your pet. I understand that my pet may not respond to CPR and may die despite CPR. I understand that the cost could substantially exceed the estimate.Initial Here*PLEASE READ CAREFULLY AND SIGN BELOWI am the owner or responsible agent for the animal described above and have the authority to execute this consent. I am over 18 years of age. I have read and understand the anesthesia and life support policy and agree. I hereby authorize the use of the appropriate anesthetics and other medication as deemed necessary by the veterinarian. I also authorize the performance of the above life support. I have had the opportunity to ask any questions that I may have regarding the anesthesia and life support policies that were given. I authorize that my credit card information be given to the Emergency Vet at time of drop off.Signature*Today's Date* Date Format: MM slash DD slash YYYY CAPTCHACommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.