Your first name
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Your last name
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Email
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example@example.com
Phone Number
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-
Area Code
Phone Number
Pet's name
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What procedure will your pet be getting?
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CT Scan
Fluoroscopy
Consent
By signing this form, you certify you'e the owner or agent of the pet, and hereby understand, consent, and authorize the following:
Click on each box to agree to approve and authorize the following items:
I understand that:
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CT scans performed under sedation or general anesthesia, and that iodine contrast solution injections may be needed for the best images..
I understand that:
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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:
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make sure my pet will be fasting (this means no food for 8 hours before procedure). If your pet is diabetic, please call us for instructions
PLEASE SIGN BELOW
(Use your mouse —or your finger on mobile). It's OK if it's not perfect!
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Submit
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