Download & CompleteClient InformationName(Required) First Last Phone Number(Required)Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Pet InformationPet's Name(Required)SpeciesColorSex Male Neutered Female SpayedBirthdate MM slash DD slash YYYY WeightAgeAuthorization for Treatment in the Event of a Life-Threatening EmergencyIn the event my pet experiences a cardiac, respiratory or other life-threatening emergency that requires resuscitative or other urgent care measures, such as cardiopulmonary resuscitation (CPR), positive pressure ventilation, emergency drugs, or other similar measures, I request that the veterinarians and/or trained staff at Finn Hill Animal Hospital pursue such medical care as indicated below. Please initial ONE of the directives listed below:Authorization Choice(Required) Resuscitate (R): I authorize emergency treatment if the situation arises (including cardiopulmonary resuscitation (CPR) and other life-saving treatments) and understand this may result in additional charges and I agree to pay for these emergency and life-stabilizing treatments even if they exceed any estimate I may have been provided. Do Not Resuscitate (DNR): I do NOT authorize emergency treatment if the situation arises (including cardiopulmonary resuscitation (CPR) and other life-saving treatments) and prefer to be contacted before any additional treatment is performed.Please select one option and provide your initials below.Client Initials(Required)Please initial your selection above.I understand that despite the best efforts of the veterinarians and staff at Finn Hill Animal Hospital, any emergency treatment, including CPR, does not guarantee or assure a favorable outcome for my pet.Phone Numbers Where You Can Be Reached TodayNote times if applicable.HomeWorkMobileOtherCertificationI hereby certify that I am the Owner or Responsible Agent of the patient identified above and that I have read and understand this authorization, including any risks associated with the treatment and care of my animal. (Must be 18 years of age or older)Signature of Owner or Responsible Agent(Required)Date(Required) MM slash DD slash YYYY Print Name(Required)CAPTCHAΔ
