Ultrasound Informed Consent Form

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Or indicate Name:

Pet's Name:

Surgical Procedure:

Pet Parents First Name:

Last Name:

Best Phone Number to reach you today:

Secondary Phone Number:

Last Mealtime:

Last Drink Time:

Current Medications/Supplements:

Other concerns:

Please read and check each box to indicate your agreement with each applicable statement.

I, the undersigned, owner or responsible party of the admitted patient, hereby authorize the veterinarians of Parkland Veterinary Clinic (and whomever they may designate as assistants) to administer such treatments as diagnostically necessary as indicated by findings during medical evaluation.

In order to obtain high quality, diagnostic images, your pet will be required to remain still during the ultrasound. In some cases, this will not be tolerated by the pet, and they will need to be sedated. Please read and check each box to indicate your agreement with each applicable statement.

I understand and accept that there is inherent risk associated with any type of sedation, including death of the patient, and I authorize the doctors of Parkland Veterinary Clinic (and whomever they may designate as assistants) to administer such treatments as necessary.

I do not want my pet to be sedated and understand acknowledge that the ultrasound may not be able to be completed. Further, I accept that I may be charged for the ultrasonographer travel fee as well as any partial charges for the incomplete ultrasound.

In the event the ultrasonographer finds any masses/tumors/questionable areas of interest, the ultrasonographer may recommend sampling of this tissue (ex. Fine needle aspirate, or biopsy). If your pet requires sampling, please read and initial one of the following statements:

I authorize the attending ultrasonographer to proceed with any tissue sampling that be recommended and take full financial responsibility for the associated additional costs where/if applicable.

I prefer NOT to have any sampling done and understand that if I change my mind at a later date, the ultrasound will need to be repeated at additional cost. I also understand that a definitive diagnosis MAY is not able to be reached if I decline recommended laboratory testing.

If your pet requires overnight hospitalization, please read the following statements and check the box that applies:

I understand and accept that there is no overnight staff on duty after the hospital closes, and that my pet will be attended to the following morning.

I prefer to take my pet to a 24-hour emergency/specialty clinic for overnight monitoring

Statement Approval

I understand that in cases where further, unforeseen work is required and is of non-emergency nature (additional diagnostics, changes to treatment plans etc.), every attempt will be made by the veterinarians/staff to contact the owner by phone to discuss the case. I also understand, if contact cannot be made in a timely manner, no additional work will be performed until informed verbal or written consent can be obtained.

Statement Approval

I hereby certify that I have read and fully understand the above authorization for medical and/or surgical treatment, and that the above procedure has been explained to my satisfaction and I have no further questions or concerns. I also certify that no guarantee or assurance has been made regarding the results that may be obtained.

Owner/Responsible Party of Admitted Animal Signature

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