(925) 228-7100 |  5055 Alhambra Ave, Martinez, CA 94553

Martinez Animal Hospital

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Authorization for Ultrasound

Name
I am the owner or agent for the above animal and have the authority to execute this consent and authorization for the Ultrasound procedure. I understand that during the performance of this procedure, unforeseen conditions may be revealed that would require my pet to be sedated. I have been advised of the nature of the services and procedure, as well as the risks involved, and I also realize the results cannot be guaranteed. I approve my pet to be sedated if necessary and accept all costs and risks associated with this. I authorize treatments deemed necessary by the veterinarian, and the administration of other medications, and understand that hospital staff will be utilized as deemed necessary by the veterinarian. I have read and understand this authorization and consent.

Please answer the questions below

DOES YOUR PET TAKE ANTI-INFLAMMATORIES*
WAS MEDICATION GIVEN TODAY?*
HAS YOUR PET HAD A RECENT (WITHIN 2 WEEKS) STEROID INJECTION?*
HAS YOUR PET BEEN FASTED?*

While hospitalized, if your pet suffers respiratory arrest (stops breathing) or cardiac arrest (the heart stops), we need to know your wishes concerning treatment

MM slash DD slash YYYY

*****Please note, we require 24 hour notice of cancellation or reschedule. If you do not provide 24 hour notice, you will be charged a $150 missed appointment fee. If a complete no show, you will be charged a no show fee of $325.*****

This field is for validation purposes and should be left unchanged.
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Martinez Animal Hospital

Phone: (925) 228-7100 Address: 5055 Alhambra Ave, Martinez, CA 94553

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