Anesthesia Consent Form for HD CT Scan
CFL
Has the pet fasted? (No food for 6 to 8 hours)
*
Pull down to select answer
Yes
No
Referring Veterinarian
*
Referring Clinic Name
*
Your first name
*
Your last name
*
Email
*
example@example.com
Pet's name
*
Species/Breed
*
Sex
*
Pull down to select answer
Male
Female
Neutered / Spayed?
*
Pull down to select answer
Yes
No
Pet's age
*
I am the owner or agent of the above-mentioned pet, and hereby understand, consent, and authorize the following procedure(s):
Please click box to authorize
*
I understand CT scans performed under sedation or general anesthesia. To enhance the images, an injection of iodine (contrast solution) is sometimes given during the exam.
Please click box to authorize
*
I understand that as with any diagnostic procedure or treatment, including anesthesia and iodine administration, rarely, there are risks which may not be predicted, including fatality. I understand these risks occur in the course of veterinary care, as veterinary medicine has no guarantees or implied guarantees of outcomes or results.
Image consent
I consent to MPI taking photos/video of my pet for medical documentation, case studies, marketing and social media use.
IMPORTANT
I certify that I have read and consented to all of the items above. Sign below (with the mouse or using your finger on mobile) and click the submit button.
Signature
*
Submit
Should be Empty:
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