Ultrasound Consent

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Pet Information* This field is required.

Pet name

Breed

Color

Sex

Age

Weight

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Your pet is having an ultrasound or echocardiogram examination today. The ultrasound examination will be done to look for any abnormalities in your pet. We recommend that you drop your pet off while the ultrasound is being performed. You will not
be int he room during the utrasound.

If your pet is having an abdominal ultrasound, the hair on the abdomen will be shaved. If your pet is having a cardiac ultrasound (echocardiogram), there will be a small patch of shaved hair on both sides of his/her chest. Some pets may become itchy after the hair has been clipped; if you find that your pet is scratching a lot at home you can apply gentle moisturizers like aloe or an oatmeal- based shampoo/lotion.

Occasionally, sedation (not general anesthesia) is necessary in order to complete the examination. We always attempt to perform ultrasound examinations without sedation and most of the time sedation is not necessary. Sometimes pets are very tense, anxious, or aggressive and sedation is required, both for their comfort and safety and for the safety of the staff holding the pet. If sedation is required, the doctor will use a light sedative tht is either reversible or wears off in a few hours.

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I * authorize the doctor to provide my pet with sedation if needed. The cost for this is $65.

When abnormalities are seen on the ultrasound examination (examples include enlarged lymph nodes and tumors), then an aspirate or biopsy of that abnormality may be taken. An aspirate or biopsy is when a small sample of tissue is taken with a needle. An ultrasound guided needle aspirate is a useful tool in obtaining information about these abnormalities. If appropriate, the doctor may use a small needle to obtain a sample of cells from an abnormal area that can be examined in the clinic or can be sent out to a pathologist for evaluation. This is a safe procedure that carries a very low risk of bleeding from the site of aspiration. Aspirations are only performed under sedation for comfort and safety.

I * authorize the doctor to obtain fine needle aspirates from abnormal tissue if he/she feels it would be appropriate. I understand that these samples will not be sent to an outside lab for examination unless I have spoken to the doctor and authorized it.

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Please ensure that we have the correct phone numbers where you can be reached today

Work Phone Number

Cell Phone

Other Phone

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In case we are unable to contact you, please give an emergency contact* This field is required.

Name

Phone

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I am the * of the animal described above, and have the authority to execute this consent. I understand that some risk always exists with sedation, even in apparently healthy animals, including the possibility of death. I have discussed my concerns with the veterinarian and understand that it may be necessary to provide additional medical or surgical treatment to my pet in the event of unforeseen circumstances. I realize that no guarantee, legal or ethical, can be made to me regarding the outcome of any procedure performed. I hereby authorize the use of sedatives and other medications, as well as any such additional treatment, as deemed necessary by the veterinarian. I understand that hospital personnel will be employed in treating my pet. I have carefully read, and fully understand, this consent. The fees associated with these services have been explained to me, and I agree to pay such fees at the time my pet is released from the hospital.

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Signature of Owner* This field is required.

Clear

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Signature of Agent* This field is required.

Clear

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Print name* This field is required.

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Date* This field is required.

Date

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Email* This field is required.

example@example.com