Ultrasound Consent Form

Please fill out this form if your pet is scheduled for an ultrasound. Thank you!

Fields marked with an asterisk (*) are required.

First Name*:

Last Name*:

Email*:

Phone*:

Home Phone:

Who is your referring veterinarian?*

Pet Name*

Pet Species*

Cat

Dog

Date*

Please check the box next to each statement below once you have read it (All are required)*

I understand that during the performance of the procedure(s), unforeseen conditions may be revealed that necessitate an extension of the foregoing procedure(s) or different procedure(s) than those set forth above. Therefore, I hereby consent to and authorize the performance of such procedure(s) as are necessary and desirable in the exercise of the veterinarian’s professional judgment.

I understand that according to law my animal should have a rabies vaccination annually or according to your county requirements and that if at this time it has lapsed, I assume full responsibility for my animal and all that he/she may come into contact with. (Required)

I have been advised as to the nature of the procedures or operations and the risks involved. I realize that results cannot be guaranteed. (Required)

I authorize the use of appropriate anesthetics and other medications and I understand the hospital support personnel will be employed as deemed necessary by the veterinarian.

I understand this procedure will require an abdominal and/or chest area to be shaved and may also require a sedative to help my pet relax during the procedure. (Required)

We require a $100 non-refundable deposit to schedule ultrasounds.*

Initial Above

I have read and understand this authorization and consent. I take full responsibility for payment at time of service.*

Initial Above

I understand that my pet must be fasted for 8 hours if having an abdominal ultrasound.*

Initial Above

I understand that my pet’s ultrasound will not be performed by a board-certified specialist unless performed by Dr. Salwei.*

Initial Above

I have been shown a treatment plan for this procedure(s).*

Yes

Pet Details

Diet: Type of food?*

Vomiting/diarrhea? Please give details (duration, frequency, color, consistency).*

Changes in appetite? Drinking? Urinating?*

Coughing or sneezing?*

Overall, how has your pet been acting?*

Is there anything else that will help us in diagnosis and treatment?*

I am the owner (or agent for the owner) of the above described animal and have the authority to execute this consent.*

Ultrasound Consent Form

Pet Details

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