MPI Consent Form INHOME

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

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). If your pet is diabetic, please call us for instructions.

What method of payment will you be using?

For any other payment options, call us:
305.733.0673

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
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Card Expiration

PLEASE SIGN BELOW
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sign here:*

Consent

Financial