Drop-off & CPR Form

  • Due to the current COVID recommendations, we have elected to use this form to streamline the drop off process. Please complete this form and let us know when you are ready for a staff member to come out to get your pet. You can either call (919)-562-0100 or text 919-569-5772. Please note, if we do not have your cell phone number we are not able to receive text messages from you. Thank you for your patience.
  • Date Format: MM slash DD slash YYYY
  • Being responsible for the above-described animal, I have the authority to grant you my consent to receive, prescribe for, treat and/or operate on my pet.
  • General Information on CPR

    Consent/Decline Directive for Cardiopulmonary Resuscitation and Release of Legal Liability
  • Should, based on the medical judgment of an Animal Diagnostic Veterinarian, my pet, require cardiopulmonary resuscitation (CPR), including cardiac compression, positive pressure respiration, emergency drugs, or other heroic interventions, I request or decline that the doctor(s) at Rolesville Veterinary Hospital pursue such medical care as indicated below.
  • Having requested such emergency procedures, I agree to be held responsible for a minimum resuscitation fee of $150.00 to pay for the services performed while staff members pursue treatment and try to reach me for further directions. Regardless of my pet's survival, I agree to pay this fee in addition to the other fees already identified by the practice and agreed upon by me. I agree that if the Rolesville Veterinary Hospital staff is unable to reach me within 15 minutes after the initiation of CPR procedures, and after exercising reasonable medical judgment, a veterinarian determines that there appears to be virtually no hope for medical success, the future CPR procedures will cease. I have been informed by Rolesville Veterinary Hospital and understand that despite the best efforts of the veterinarian and staff at Rolesville Veterinary Hospital, CPR may not save my pet's life. I also understand that even the most successful CPR that restores my pet's life may not allow my pet to regain his/her normal mental and physical health, and thus may leave him/her as invalid.
  • DO NOT RESUSCITATE MY PET. I have read the above information and release. I agree to the above terms and request that NO CPR BE PERFORMED ON MY PET.
  • Owner/Responsible Party
  • Date Format: MM slash DD slash YYYY
COVID-19 ANNOUNCEMENT: The safety of both our staff and clients is of the utmost importance to Rolesville Animal Hospital. Please read our new implementations, effective immediately.Read More