Advanced Directive for Medical Care

Advanced Directive for Medical Care in Owner’s Absence

Owner's Name *

First

Last

Phone *

Email *

Pet Name *

Species/Breed *

Sex/Age *

If my pet is suffering from an injury, illness, or disease; medical treatment, resuscitative efforts, or humane euthanasia may become necessary. Should, based on the medical judgment of the veterinary staff, my pets medical condition deteriorate, and I cannot be reached to make timely decisions regarding his/her care (or that my emergency contact person is unable to be reached), I request that Centennial Animal Hospital make medical care decisions as indicated below. *

I understand.

The following is the maximum allowable amount to be spent for veterinary services in the care of a life-threatening or non-life-threatening, unforeseen medical condition, illness, or injury that arises during my pet's stay. Centennial Animal Hospital, acting in its sole discretion after making reasonable attempts to contact the owner or emergency contact provided, may perform services deemed necessary by the veterinarian, give requisite attention or administer medications not to exceed the above-listed amount. If applicable, I understand that the above amount's repayment will be due in full at the time of check out. *

Please choose the dollar ($) amount not to be exceeded.

I understand and authorize that additional emergency or continuing medical treatments may be necessary for my pet. I authorize Centennial Animal Hospital to act on my behalf should my pet need to be transferred to an emergency or specialty hospital for continued care. Emergency and specialty care typically start around $1000 and go up there depending on the illness or injury's seriousness. *

I agree.

Cardiopulmonary Resuscitation (CPR) *

Request for CPR - I direct that, if required, CPR be performed on my pet, which means all medically reasonable attempts will be made to resuscitate my pet. I understand that the survival rate of animals requiring CPR is poor (less than 10%). I further understand that staff is not on the premises at Centennial Animal Hospital from 6 PM to 8 AM, and during these hours, CPR is not possible.
Decline CPR - I direct that no attempt to resuscitate my pet be made, which means withdrawing all life-sustaining procedures, methods, and devices. This is including cardiopulmonary resuscitation, respiratory support, injectable medications, and artificially administered feeding and fluids).

Humane Euthanasia *

Request for Humane Euthanasia - In the case of sudden deterioration of the health of my pet (such that he/she appears to be experiencing pain or suffering that cannot be ameliorated with medications or supportive care), I direct that my pet be humanely euthanized to prevent such further pain or suffering. The cost estimate for humane euthanasia is typically under $200.
Decline Humane Euthanasia - I direct that humane euthanasia not be performed on my pet without my prior consent, even in the instant of extreme pain or suffering.

Pet Remains – In the unlikely event my pet passes away during his/her boarding stay, I wish for their remains to be: *

Solo Cremation - Pets are cremated individually, and ashes are returned to the owner.
Partitioned Cremation - A method of separation is used between each pet. The remains of each pet are both identifiable and retrievable to ensure that it is your pet. Ashes are returned to the owner.
Communal Cremation - Multiple pets are cremated together, and ashes are scattered on a private ranch in the mountains.

Please check the box below if you would also like an imprint of your pet's paw:

Clay Paw Print – This is an impression of your pets imprint in clay.

We will make every reasonable attempt to contact you should your pet become ill or injured during their stay at Centennial Animal Hospital. *

I understand.

Any decision you make while on the phone shall supersede your written directives. *

I understand.

If we are unable to reach you, we will attempt to reach your emergency contact. Please discuss your wishes with them so they can be prepared to make decisions on your behalf. *

I understand.

Should something happen to me, I give the following person authorization to pick-up, care for, and authorize any and all medical care for my pet. I also give permission for my records to be transferred on request to another veterinary clinic should the person named below deem it necessary. *

First

Last

Phone *

Liability Release - In consideration for following my wishes, I hereby forever release Centennial Animal Hospital, its staff, and authorized representatives from any and all liability and claims for damages, including claims for death, injury, or property damage, whether or not resulting from negligence or misconduct attributable to such parties, that I may have or that may subsequently accrue to me, as a result of honoring this directive, and I declare that such parties are acting in accordance with my directions. I further agree to indemnify such parties for any third-party claims that I am not authorized to act on the animal or owner’s behalf. *

I agree.

I certify that I am the legal owner or the duly authorized agent for the pet's owner identified above. I understand that my wishes may be carried out immediately upon my signing this agreement. Applicable fees have been explained to me, and I assume full responsibility for all charges applicable to these services. I have carefully read and fully understand the foregoing provisions. I agree to reimburse Centennial Animal Hospital for any additional fees for tending to emergency or veterinary care as well as any expenses incurred for any other unexpected food or other supply needs. *

I agree.

I understand that this Advanced Medical Directive shall exist indefinitely from the date I execute this document unless I revoke it in writing or replace it with a new advanced medical directive. *

I agree.

Owner's Signature *

Clear Signature

Date *

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We treat your pets like the valued family members they are.

Address

6870 Centennial Blvd.
Colorado Springs, CO 80919
Click here for directions.

Hours

Mon – Fri: 8:00 am – 6:00 pm
Sat: 8:00 am – 12:00 pm
Sun: Closed

Contact

Phone: 719-528-1693
Fax: 719-528-1694
Email: centennialpets@gmail.com

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