Anesthesia Consent for HD CT Scan
South Florida
IMPORTANT:
THIS FORM IS FOR
CT SCANS ONLY
If your pet is scheduled for a FLUOROSCOPY, you MUST fill out the FLUOROSCOPY form instead.
CLICK FOR FLUOROSCOPY FORM
Has the pet fasted? (No food for 6 to 8 hours)
*
Please Select
Pull down to select answer
Yes
No
Referring Veterinarian
*
Referring Clinic Name
*
Your first name
*
Your last name
*
Email
*
example@example.com
Pet's name
*
Species/Breed
*
Sex
*
Pull down to select answer
Male
Female
Neutered / Spayed?
*
Pull down to select answer
Yes
No
Pet's age
*
I am the owner or agent of the above-mentioned pet, and hereby understand, consent, and authorize the following procedure(s):
Please click box to authorize
*
I understand CT scans performed under sedation or general anesthesia. To enhance the images, an injection of iodine (contrast solution) is sometimes given during the exam.
Other
Please click box to authorize
*
I understand that as with any diagnostic procedure or treatment, including anesthesia and iodine administration, rarely, there are risks which may not be predicted, including fatality. I understand these risks occur in the course of veterinary care, as veterinary medicine has no guarantees or implied guarantees of outcomes or results.
Image consent
I consent to MPI taking photos/video of my pet for medical documentation, case studies, marketing and social media use.
IMPORTANT
I certify that I have read and consented to all of the items above. Sign below (with the mouse or using your finger on mobile) and click the submit button.
Signature
*
Submit
Should be Empty: