CPR/DNR Form CPR DNR Consent Form Location * Please SelectPrimary Care Membership - Jeffrey LocationEmergency - Sand Canyon Location Today's Date * Email * Owner's Name * Owner's Name First First Last Last Authorized Agent's name (if different from Owner) Patient's Name * Species (Canine, Feline, Rabbit, etc) * Patient's Birthday * Patient's Sex (Male, Female) * I am the owner or the authorized agent for the owner of the patient described above, and I have the authority to execute this consent. My signature initials below certify that I am over eighteen years of age. In the event that the patient described above should experience cardiac or respiratory arrest while being hospitalized today, do you give consent for resuscitative efforts to be initiated until you can be contacted further and notified of the patient’s status? By consenting to this service, you are also acknowledging that certain fees will apply. If you are not able to be contacted immediately, resuscitation efforts will be continued to be performed at the doctor’s discretion. Please initial your choice below. In case of arrest * I agree to CPR being performed I elect a Do Not Resuscitate status Signature * signature keyboard Clear Today's Date By checking this box, I authorize an electronic signature. * I authorize Captcha Submit If you are human, leave this field blank.
