Outpatient Ultrasound Scheduling - Intake Form

If you are a veterinarian needing to fill out a referral form, please go to https://www.ssvetimaging.com/outpatient-veterinarian-referral

I hereby authorize the veterinarians of South Sound Veterinary Imaging, all of their affiliates, and their respective employees, agents, contractors, and representatives (collectively the “Medical Professionals”) to administer treatment as is considered therapeutically and/or diagnostically necessary.

I authorize medical treatment, as well as possible alternative modes of treatment, as explained to me by the Medical Professionals. I further authorize interventional procedures of an emergency nature, if deemed necessary.

The deposit is non-refundable if I cancel my appointment less than 48 hours before scheduled appointment. For those eligible for refund, a service fee ($8) will be subtracted from refundable amount.

I give my permission to release case/patient information and/or photos so they may be used in teaching, continuing education, website, veterinary literature, and the like while patient confidentiality will be maintained.

I consent to the release of all of my medical information to South Sound Veterinary Imaging, my provided veterinarian and affiliates.

I assume full financial responsibility for all charges incurred for the care and treatment of this patient. Unpaid balances over 30 days will accrue an interest rate charge of 2% per month. I understand that if collection action should become necessary for recovery of any monies due under this contract, I agree to pay any and all collection costs up to 40%, court costs, and reasonable attorney fees.

Information provided by me is solely for the use of the Practices and for any practice which hereafter begins performing veterinary services at the same premises as conducted by the Practices or in conjunction with the Practices.

I certify that I am at least 18 years of age and have the authority to make decisions on behalf of the patient.

If tissue abnormalities are detected in your pet, ultrasound guided fine needle aspirate (FNA) maybe recommended by our radiologist. In these cases, an ultrasound is used to guide a small needle into a suspected area of abnormal tissue to obtain cells or tissue for submission to our outside laboratory for analysis.

A small amount of bleeding is common with fine needle aspiration and/or biopsy, usually with no further consequences. Severe bleeding seldom occurs, but can rarely lead to serious complications requiring intervention.

These procedures will only be performed if required for proper diagnosis and treatment. Sufficient platelet count within the past 30 days is required for same-day procedures. In some cases, clotting times may be indicated as well.

If recent bloodwork is needed and/or not obtainable at time of service, your pet can have the test completed at our office or your regular veterinarian. A follow-up appointment would be needed for this procedure.

We highly recommend asking your veterinarian for oral anti-anxiety medications if you anticipate needing FNA at same time of visit.

Your pet will be evaluated and monitored carefully by your veterinarian before, during, and after these procedures to minimize the risk of serious complications from occurring. After care instructions will be provided.

Continue to give your pet water as normal prior to the exam.

Please withhold your pet's food whenever possible for 8 hours prior to appointment time. Water is ok.

Please try to prevent your pet from urinating at least 2 hours prior to ultrasound, as a full bladder helps us visualize structures in and around the bladder.

If your pet is taking any medication that you are uncertain should be given the day of the procedure, please contact your primary veterinarian for advice.

Failure to follow preparation guidelines may result in inadequate images and necessity to repeat study at additional costs. We understand sometimes oversights happen, if you have any questions please contact us.