Ultrasound Consent Form

"*" indicates required fields

We place the highest priority on ensuring you feel comfortable with the plan for your pet’s care and fully understand the authorizations below before giving your consent. If you have any questions or need clarification on any of the choices, please contact the hospital so a medical team member can review the form with you prior to completing it. As always, thank you for entrusting us with your pet’s care!

Appointment Date*

Appointment Time*

AM/PM

Client's First Name*

Client's Last Name*

Best Contact Number*

Email*

Pet's Name*

Species*

Canine

Feline

Ultrasounds at Health and Harmony Animal Hospital are done by a mobile service and not performed by our veterinarians. Abdominal ultrasonography is a non-invasive technique used to image organs within the abdomen and/or chest. The area to be imaged must be shaved in order to provide adequate imaging. Irritation may occur to the skin as a consequence. Hair regrowth generally takes multiple weeks to occur, but can be more prolonged in certain pets.

Consent*

I have read and authorize

I understand that my pet may require sedation in order to obtain diagnostic images and authorize the veterinarian to administer sedation if necessary. I understand this will incur an additional cost of $50-100.

Consent*

I have read and authorize

I acknowledge that the procedure has been explained to my satisfaction and I authorize an ultrasound examination to be performed on my pet.

Fine needle aspiration is a procedure involving placement of a needle, using the guidance of an ultrasound, into an organ or mass. A tissue sample is drawn into the needle and sent in for diagnostic testing. This procedure is often the first step towards diagnosing abnormalities identified on ultrasound examination. Fine needle aspiration is generally a safe procedure, but with any procedure there are always inherent risks. If the veterinarian deems a fine needle aspirate necessary*

I authorize fine needle aspirates recommended by the veterinarian and do not wish to be contacted prior to the aspirate. I understand this will incur additional costs.

I wish to be contacted prior to the fine needle aspirate being performed. I understand this may delay diagnostic treatment and may require additional ultrasounds in the near future.

In the event of an unforeseen emergency, if your pet were to go into cardiac or respiratory arrest, please indicate what life-saving measures you would like the doctors and medical staff to take by selecting ONE choice below*

Please attempt resuscitation by performing CPR (cardiopulmonary resuscitation). Life-saving measures may include, but are not limited to, external chest compressions, securing an airway, giving oxygen, placing an IV catheter, and administering any necessary drugs. I understand that there are additional costs associated with life-saving measures and that resuscitation is not appropriate for every patient that has gone into cardiac arrest.

Please DO NOT perform life-saving measures.

Signature*

Date*

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Phone

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What's Next

1
Call us or schedule an appointment online.
2
Meet with a doctor for an initial exam.
3
Put a plan together for your pet.

Make An Appointment

What's Next

Call us or schedule an appointment online.

Meet with a doctor for an initial exam.

Put a plan together for your pet.

Where family pets find loving care