Ultrasound Consent Form

Name*

First Name Last Name

Phone Number*

Please enter a valid phone number.

Pets Name*

List any current medications, including name, dosage and time last given. Please include any supplements.*

Any previous issues with sedation or anesthesia? If yes, please explain. *

What are the presenting symptoms your pet is experiencing?*

If we find any abnormalities during the ultrasound, do we have permission to obtain aspirates for ctyology?*

yesCall FirstNo

I verify that I am the owner (or authorized agent for the owner) of the above named pet and authorize the Ultrasound to be preformed by Advanced PetCare of Oakland. I authorize the use of sedation and other medication as deemed necessary by the veterinarian.*

AgreeDisagree

I have been advised as to the nature of this procedure to be preformed and the risks involved, which can include serious bodily injury or death. No guarantees have been made regarding the outcome or cure. I understand that there is always risk associated with any sedation procedure, even in apparently healthy animals, and have discussed my concerns with the Veterinarian. The veterinarian has provided me the opportunity to ask questions and receive answers regarding the procedure.*

AgreeDisagree

In the event of an unforeseen emergency, we will attempt to reach you without delay. Please know that we will take every precaution to ensure that your pet is safe and healthy enough to undergo their procedure today. Any known risks will be discussed with you. However, very rarely, emergencies do happen and we want to know your preference if no one can be reached. Please check your preference:*

Please proceed with CPR. I accept responsibility for all costs incurred.Please do not proceed with CPR

We submit our ultrasound images to a specialist to review them, we will contact you within a week to go over the results/*

Agree

Signature

Clear