Ultrasound Consent Form

Greenbank Animal Hospital

Nepean-Rideau Veterinary Professional Corporation

3160 Greenbank Rd

Nepean, ON K2J 4H6

(613) 825-2902

INTERNAL USE: Client file number, Patient ID number, Patient weight (kg)

Client name*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

Pet's name*

Pet's Date of Birth

Species*

Breed

Colour

MaleMale/neuteredFemaleFemale/spayed

Contact phone number day of procedure*

Please enter a valid phone numberFormat: (000) 000-0000.

Alternate contact phone number day of procedure*

Please enter a valid phone number.Format: (000) 000-0000.

Your pet is being admitted for the following authorized procedure(s)*

Date of the scheduled procedure

MonthDayYear

YesNo

Please list the name, date, and time of all medications that will be given to your pet 24 hours ahead of admit time*

Please provide the name, date, and time of any other medications given to your pet 7 days prior to the procedure

I have read and understand the cancellation policy outlined above

Proceed with any necessary procedures that are in the best interest of my pet and charge accordinglyCancel the procedure and charge for any expenses incurred.

Proceed with any necessary procedures that are in the best interest of my pet and charge accordinglyDo not proceed further and DO NOT RESUSCITATE.

I confirm

I agree

I confirm

RISKS

The following are some risks associated with our most commonly performed procedures. Please note that this in not a comprehensive list and other less common issues may arise.

While we take every precaution necessary and you may rest assured that your pet will be monitored constantly throughout the procedure, there are risks associated with administering anesthesia such as aspiration pneumonia and in extremely rare instances, cardiac arrest and stroke.

General Anesthetic Risks:

Aspiration Pneumonia- this can occur during or after the procedure if fluid or food is regurgitated into the throat and mouth during the procedure. Pneumonia may develop if the fluid or food is inhaled into the lungs.

Diarrhea-gastrointestinal upset can occur after general anesthetic

Allergic Reaction- an allergic reaction to medication(s) may result in facial swelling, hives, itchy skin, vomiting, diarrhea, respiratory changes and/or loss of appetite. In some cases, a reaction to the suture material can result in redness, swelling and inflammation of the incisional area.

I agree

Please verify that you are human*