Ultrasound Consent Form

Please complete the form below as accurately and completely as possible. If you have any questions, you can contact us at 419-517-5042.

Client Name *

First

Last

Phone Number *

Email *

Patient Name *

Ultrasonography is a non-invasive form of imaging to evaluate the organs within the abdomen and/or chest. The area to be imaged will 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 may be more prolonged in certain pets.

Your pet may require sedation in order to obtain diagnostic images with ultrasound. *

I authorize sedation to be given if necessary. I understand this will add an additional cost as outlined in the provided estimate.
I decline sedation. I understand diagnostic images may not be able to be obtained and/or the ultrasound procedure will be stopped due to patient and/or staff safety concerns.

If an abnormal fluid or tissue is identified, a fine needle aspirate can be performed. A fine needle aspirate involves using a needle, under the guidance of the ultrasound, to sample tissue or fluid, which can be sent in for diagnostic testing. The cost of the sampling and submission for a board certified pathology review has been outlined in your provided estimate. If the veterinarian determines a fine needle aspirate is indicated: *

I authorize fine needle aspirates 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.

I verify I am the owner (or Authorized agent for the owner) of the above named pet and authorize the above procedure to be performed. I authorize the use of sedation and other medication as deemed necessary by the veterinarian and understand that hospital personnel will be employed in the procedure(s) as directed by the veterinarian. *

I have read and agree

I have been advised as to the nature of this procedure to be performed and the risks involved. I understand also that there is always a risk associated with any sedation episode, even in apparently healthy animals, and have discussed my concerns with the veterinarian. I understand that it may be necessary to provide medical and/or surgical procedures which are not anticipated for the safety or care of my pet. I hereby consent to and authorize the performance of such altered and/or additional procedures as are necessary in the veterinarian’s professional judgement. *

I have read and agree

I accept responsibility for any result in additional charges. I agree to be responsible for any charges incurred while my pet is in the care of this facility and understand payment is due at the time my pet is released from the hospital. I understand a veterinary staff member will be caring for my pet overnight; however, no veterinarian will be routinely present in the building overnight. *

I have read and agree

Additional Procedures to be performed today:

Best phone number(s) to reach you at:

Last time had food:

Last time had water:

Special feeding instructions:

Current Medications:

Client Signature *

Clear Signature

Date *

Website

Compassionate veterinary care in Sylvania, OH!

We treat each patient as our own. Our team is here to help when you need us most! We look forward to seeing you.

Location

7851 W Sylvania Ave.
Sylvania, OH 43560

Hours

Mon – Fri: 8:00am – 6:00pm
Sat: 8:00am – 1:00pm

Please Note: We are closed from 1pm to 2pm, Monday through Friday.

Contact Info

Phone: 419-517-5042
Email: info@timberstonevet.com
Fax: 419-517-5044