Ultrasound Drop Off Form
*FOR THE SAFETY OF OUR STAFF AND CLIENTS PLEASE ARRIVE WEARING A MASK AND MAINTAIN 6 FOOT DISTANCE AT ALL TIMES*
Date of Procedure:
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/
Month
/
Day
Year
Date
Name
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First Name
Last Name
Email Address:
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Phone Number (where you can be reached today):
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-
Area Code
Phone Number
Alternative Phone Number
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-
Area Code
Phone Number
What veterinarian that has been seeing your pet:
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Pet's Name:
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Was your pet fasted?
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Yes
No
Is your pet taking any medications?
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Yes (please fill out sections below)
No
Medication Name, dose given, date last given?
Medication Name, dose given, date last given?
Medication Name, dose given, date last given?
Medication Name, dose given, date last given?
Any NEW changes or concerns the vet should know about since last visit? Write "none" if no new changes.
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INITIAL BELOW:
I understand that an estimate of charges was given, the estimate is only an approximation and that unforeseen circumstances may result in final charges may be substantially greater than the estimate. I understand that any estimate given is in additional to any doctor consultation and treatments performed.
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Initial
I understand that my pet will be shaved to allow the ultrasonographer to properly assess my pet during the procedure.
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Initial
I authorize Midvalley Animal Clinic to do the preceding services on my pet. I understand the following (1) No guarantee of successful outcome of treatment is either expressed or implied. (2) Risks are involved in the treatment of any condition including death.
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Initial
understand all fees for services are payable by cash, check, or credit card and are due at the time services are rendered. I understand that any past due accounts are subject to all costs of collection, including legal fees.
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Initial
I am the owner/authorized agent of the pet presented for care.
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Initial
By signing below you agree to all terms of this form:
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