Ultrasound ConsentName(Required) First Last Email(Required)Phone(Required)Secondary PhoneAlternate PhoneWho is your referring veterinarian?(Required)Pet Name(Required)Pet Species(Required)DogCatDate(Required) MM slash DD slash YYYY 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.(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 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.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 have been advised as to the nature of the procedures or operations and the risks involved. I realize that results cannot be guaranteed.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 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) 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.We require a $100 non-refundable deposit to schedule ultrasounds.(Required)Initial HereI have read and understand this authorization and consent. I take full responsibility for payment at time of service.(Required)Initial HereI understand that my pet must be fasted for 8 hours if having an abdominal ultrasound.(Required)Initial HereI understand that my pet’s ultrasound will not be performed by a board-certified specialist unless performed by Dr. Salwei.(Required)Initial HereI have been shown a treatment plan for this procedure(s).(Required) Yes NoDiet? What type of food?(Required)Vomiting/diarrhea? Please give details (duration, frequency, color, consistency).(Required)Changes in appetite? Drinking? Urinating?(Required)Coughing or sneezing?(Required)Overall, how has your pet been acting?(Required)Is there anything else you think will help us in diagnosis and treatment?(Required)I am the owner (or agent for the owner) of the above described animal and have the authority to execute this consent.(Required) I am the owner (or agent for the owner) of the above described animal and have the authority to execute this consent.Signature(Required)CAPTCHAΔ
