MPI Consent Form

Your first name*

Your last name*

Email*

example@example.com

Phone Number*

Area CodePhone Number

Pet's name*

What procedure will your pet be getting?*

CT ScanFluoroscopy

Where are you located?*

South Florida AreaOrlando Area

Is your vet a Banfiled Clinic?*

YesNo

Click on each box to agree to approve and authorize the following items:

I understand that:*

CT scans performed under sedation or general anesthesia, and that iodine contrast solution injections may be needed for the best images..

I understand that:*

as with any diagnostic procedure or treatment, including anesthesia  and iodine administration, there are rare, unpredictable risks—including fatality. Veterinary medicine has no guarantees or implied guarantees of outcomes or results.

I consent to:

MPI taking photos/video of my pet and procedure for medical documentation, case studies, marketing and social media use; in perpetuity.

I agree to:*

make sure my pet will be fasting (This means no food for 8 hours before procedure)

What method of payment will you be using?

For any other payment options, call us:
407.913.5514

Click below to submit your CareCredit card info and the front of your Driver's License.

You can also email us pics: info@mobilepetimaging.com

Take photo of your Driver's License

WE REQUIRE A NON-REFUNDABLE DEPOSIT. Changes / cancellations with less than 24 hours' notice will result in forfeiture of deposit.

Please check the appropriate deposit:*

CT Scan DEPOSIT$750.00

This is ONLY a DEPOSIT— the balance will be due on the day of procedure. The full amount for procedure will be quoted to you via phone or email— NOTE: Changes or cancellation with less than 24 hours notice will result in forfeiture of this deposit.

Fluoroscopy DEPOSIT $350.00

This is ONLY a DEPOSIT— the balance will be due on the day of procedure. The full amount for procedure will be quoted to you via phone or email NOTE: Changes or cancellations with less than 24 hours' notice will result in the forfeiture of this deposit.

Total $0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

PLEASE SIGN BELOW
(Use your mouse —or your finger on mobile). It's OK if it's not perfect!

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Consent

Financial