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Hours 2752 W Lawrence Ave Suite 3
Chicago, IL 60625

Code Status Form

First Name:*

Last Name:*

Preferred Phone Number:*

Pet's Name:*

Today's Date:*

Typed Signature:*

Animal House of Chicago 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. Whether your pet is here for an annual exam or advanced medical concerns, emergencies can happen at any time. It is appropriate to decide in advance as to whether aggressive measure 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 often in extremely critical condition and may be unstable. Referral to a 24/7 urgent care facility post successful resuscitation may be recommended. 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 Animal House of Chicago, its agents and representatives, from liability for any and all damages to my pet. I agree to hold Animal House of Chicago, 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.*

I agree

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 and 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 accept

If I request such emergency procedures, I agree to be held responsible for the veterinary services provided to my pet regardless of recovery or survival, including CPR fees in addition to other agreed-upon charges.

I accept

Animal House of Chicago