Advance Medical Directive Form

Save time during your next appointment! Complete your advance medical directive form online before your visit.

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

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Pet’s Name*

Owner’s Name*

Email*

Please select one option*

CPR (Cardiopulmonary Resuscitation)

Do Not Resuscitate (DNR)

CPR (Cardiopulmonary Resuscitation):

Should the above pet require cardiopulmonary resuscitation (CPR), including cardiac compression, positive pressure respiration, emergency drugs, or other heroic interventions, I request that the veterinarian(s) of Old Dominion Animal Health Center pursue all measures available in an effort to save the life of my pet.
I understand that the first hour of critical /emergency care could be approximately $2,200 and depending on response of the pet, each additional hour could incur fees of $800 to $1,200.
If, in the opinion of the veterinarians, my pet’s condition becomes such that there is no reasonable expectation that my pet will recover, my pet’s condition is irreversible, and my pet is suffering, then I authorize the veterinarians of Old Dominion Animal Health Center to euthanize my pet.

Do Not Resuscitate (DNR):

I do not wish for my pet to undergo cardiopulmonary resuscitation (CPR) or other heroic measures in the event of a critical illness or life-threatening event.
If my pet's condition becomes such that there is no reasonable expectation of recovery and my pet is suffering, I authorize the veterinarians of Old Dominion Animal Health Center to euthanize my pet.

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