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Doggie DNR Form

Please fill out completely and accurately.

"*" indicates required fields

Enter your Dog's name.
Enter your breed of Dog.
Sex of Dog.
Enter Dog's Birthday if you know it. (If not leave blank)
MM slash DD slash YYYY
Enter Dog's age.
Enter Dog's Micro Chip Number.
If you have Pet Insurance enter who it is with. (If none leave blank)
If you have Pet Insurance enter the phone number. (If none leave blank)
Enter your Dog's Medical history if any.
Enter any Medications your dog may be taking or any specific Allergies.
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).
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: 1 GB.
Owner's Name*
Dog owner's name
Owner's Name
Additional Owner's Name
Owner's Address*
Owner's Address
Owner's phone number
Owner's Email address.
Dogs Veterinarian Office/Clinic
Who is the Dog's Veterinarian?
Veterinarian Address.
Enter the Dog's Veterinarian's address.
Enter Dog's Veterinarian's phone number.
Enter your Pet Sitter/Doggie Day Care business name.
Enter Contact person- Pet Sitter/Doggie Day Care.
Enter the Doggie Day Care/ Pet Sitters phone number.
Enter the Doggie Day Care/ Pet Sitters email address. (if none leave blank)
Do you want your Dog to receive CPR. (Cardiopulmonary Resuscitation) Dog has no pulse and not 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.)
Choose one of the following:

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

2. Use antibiotics.
Choose one of the following:

1. No artificial nutrition/hydration by tube.

2. Use artificial nutrition/hydration.
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.