Doggie DNR Form

Dog Name*

Enter your Dog's name.

Dog Breed*

Enter your breed of Dog.

Sex*

Sex of Dog.

Dog's Birthday.

Enter Dog's Birthday if you know it. (If not leave blank)

Dog's Age.*

Enter Dog's age.

Pet Microchip Number.

Enter Dog's Micro Chip Number.

Pet Insurance Company

If you have Pet Insurance enter who it is with. (If none leave blank)

Pet Insurance Phone Number

If you have Pet Insurance enter the phone number. (If none leave blank)

Medical History

Enter your Dog's Medical history if any.

Medications/Allergies

Enter any Medications your dog may be taking or any specific Allergies.

Special Instructions.

Enter any special instructions you may have. (May be used for specific instructions in regards to your dog, guidance on medication, how much and when to give).

Dog Photo.*

Upload current photo of your Dog. MAKE Sure the photo is oriented correctly! (Smartphones support what's known as EXIF image data which includes an orientation option) Save the image upright prior to uploading!

Accepted file types: jpg, gif, png, Max. file size: 32 MB.

Owner's Name*

Dog owner's name

First Last

Owner's Name

Additional Owner's Name

First Last

Owner's Address*

Owner's Address

Street Address City State ZIP Code

Phone*

Owner's phone number

Owner's Email*

Owner's Email address.

Dog's Veterinarian Clinic.

Dogs Veterinarian Office/Clinic

Veterinarian.

Who is the Dog's Veterinarian?

Veterinarian Address.

Enter the Dog's Veterinarian's address.

Street Address City State ZIP Code

Veterinarian Phone.

Enter Dog's Veterinarian's phone number.

Doggie Day Care/Sitter Business.

Enter your Pet Sitter/Doggie Day Care business name.

Doggie Day Care/Sitter Contact.

Enter Contact person- Pet Sitter/Doggie Day Care.

Doggie Day Care/Sitter Phone.

Enter the Doggie Day Care/ Pet Sitters phone number.

Doggie Day Care/Pet Sitter Email.

Enter the Doggie Day Care/ Pet Sitters email address. (if none leave blank)

Box A - CPR*

Do you want your Dog to receive CPR. (Cardiopulmonary Resuscitation) Dog has no pulse and not breathing.

Box B - MEDICAL INTERVENTIONS (Dog has pulse and/or is breathing)*

Choose one of the following:

1. Comfort measures only: (Use medication by any route, positioning, and any other measures to relieve pain and suffering including Oxygen, Suction and manual treatment of airway obstruction as needed for comfort. Do not transport to the Veterinarian for life sustaining treatment.)

2. Limited Additional Interventions: (Use medical treatment, IV, fluids and cardiac monitor as indicated. Do not use intubation, advanced airway interventions, mechanical ventilations. Transfer dog to the Veterinarian.)

3. Full Treatment: (Include care as described above. Use intubation, advanced airway interventions, mechanical ventilation, and cardioversion as indicated. Transfer dog to the Veterinarian.)

Box C -ANTIBIOTICS*

Choose one of the following:

1. No antibiotics (Use other measures to relieve symptoms.)

2. Use antibiotics.

BOX D - ARTIFICIALLY ADMINISTERED NUTRITION AND HYDRATION.*

Choose one of the following:

1. No artificial nutrition/hydration by tube.

2. Use artificial nutrition/hydration.

Liability Acknowledgment.*
By clicking yes you fully understand that This Doggie DNR has no legal binding and you should consult with your Veterinarian before using this from.