Fluoroscopy Anesthesia Consent

Anesthesia Consent Form for Fluoroscopy
IMPORTANT:
THIS FORM IS FOR
FLUOROSCOPY
ONLY

If your pet is scheduled for a CT SCAN, you MUST fill out the CT SCAN form instead.
CT SCAN CONSENT FORM
Has the pet fasted? (No food for 6 to 8 hours)*
Referring Veterinarian*
Referring Clinic Name*
Your first name*
Your last name*
Pet's name*
Species/Breed*
Sex*
Neutered / Spayed?*
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 check the left hand box on each item below to indicate your consent for each.*
By clicking on the submit button, I certify that I have read and consented to all of the items above.
Image Consent
Signature*
Should be Empty:

Anesthesia Consent Form for Fluoroscopy