Code Status Form Code Status Form Code Status Form Yalesville Veterinary Hospital is committed to providing patients with state-of-the-art medical care that considers the quality, as well as the length of a pet’s life. For patients experiencing advanced disease, advanced age, multiple disease processes, and/or a disease considered to be terminal, it is appropriate to decide in advance as to whether aggressive measures of resuscitation (CPR) will be employed if needed. DNR means “do not resuscitate”. This is a decision that resuscitation (CPR) is not to be performed in the event that the pet stops breathing, does not have a heartbeat, collapses, or becomes unconscious. Cardiopulmonary Resuscitation (CPR) of a collapsed or unconscious patient is tailored to meet the needs of the individual, but may include any or all of the following: Establishing an airway via insertion of an endotracheal tube and administration of supplemental oxygen and/or medications through said tube Establishing intravenous access via insertion of an intravenous catheter as well as administration of intravenous fluids and injectable medications through said catheter Chest compressions Intracardiac delivery of injectable medications Animals that have survived cardiopulmonary arrest and have been successfully resuscitated (CPR) are in extremely critical condition and are unstable. Management of the post-arrest patient requires vigilant monitoring as well as technical expertise of dedicated critical care personnel. This care is costly, and the outcome is uncertain. I acknowledge that I have read and understood the information provided above or have had it explained to my satisfaction. I understand that the anesthetic, surgical, or therapeutic procedures and treatments my pet is undergoing today may involve the risk of complications, injury, or even death, from both known and unknown causes, and no warranty or guarantee has either been expressed or implied as to the result or cure. Hereby, I expressly agree to release Yalesville Veterinary Hospital, its agents and representatives, from liability for any and all damages to my pet. I agree to hold Yalesville Veterinary Hospital, its agents and its representatives harmless from any liability (except in the case of gross negligence) associated with the procedure and treatments being performed on my pet. DNR: I DO NOT wish the staff to perform CPR on my pet. I understand that if my pet suffers from cardiac arrest, pulmonary arrest, collapse, or unconsciousness that if CPR is not performed, my pet will pass away. I do not wish CPR: I wish the staff to perform cardiopulmonary resuscitation (CPR) on my pet if my pet suffers from cardiac arrest, respiratory arrest, collapse, or unconsciousness. I wish I accept that if the hospital staff is unable to reach me within 20 minutes after the initial CPR procedures, and after exercising reasonable medical judgment, determine that there is no hope for success, the staff will cease further CPR procedures. I understand that despite the best effort of the veterinarians and staff at this facility, even the most successful CPR that may restore my pet’s life, may not allow for my pet to regain his/her normal mental and physical health. I accept If I request such emergency procedures, I agree to be held responsible for the veterinary services provided to my pet while staff members pursue treatment and try to reach me for further directions. Regardless of my pet’s recovery or survival, I agree to pay CPR fees in addition to other fees already identified by the practice and agreed upon by me. I request Name * Name First First Last Last Pet's Name * Phone * Email * Signature * signature keyboard Clear Date * Submit If you are human, leave this field blank.
