CT Authorization Form Your Name* First Last Procedure*For Safety We Require The Following:A current exam and lab tests no more than 30 days prior to the procedureA copy of medical notes and lab results if you’re being referred by another HospitalMonitoring of vital systems Advances in medicine have made most procedures quite safe, with a low rate of complications. However, occasional problems can arise if the veterinarian is not aware of the pre-existing conditions which may not be evident during the pre-CT examination.Emergency CPR Authorization:Please select one of the following:* In the event that my pet suffers respiratory or cardiac arrest, I give permission to the staff of Partridge Animal Hospital to perform CPR while I’m being informed of the condition of my pet and my options. If Partridge Animal Hospital is unable to reach me CPR can continue as deemed necessary by the Veterinarian. In the event that my pet suffers respiratory or cardiac arrest, I DO NOT give permission to the staff of Partridge Animal Hospital to perform CPR. I elect to have DNR (Do Not Resuscitate) orders places on my pet’s record.I understand that my pet may not respond to CPR or may respond initially and then suffer another arrest later. *Additional charges will apply.* I undertand the aboveI have been advised of the nature of the services and procedures, as well as the risks involved, and I also realize the results cannot be guaranteed.* I undertand the aboveI am the owner of the above patient and have the authority to execute this consent and authorization*(Initial)All charges shall be paid at the time of drop off.* I have read and understand this authorizationSignature*Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.Δ
