Authorization for Ultrasound Name First Last Pet's NameI 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 belowDOES YOUR PET TAKE ANTI-INFLAMMATORIES* YES NOWAS MEDICATION GIVEN TODAY?* YES NOWHICH ONEHAS YOUR PET HAD A RECENT (WITHIN 2 WEEKS) STEROID INJECTION?* YES NOHAS YOUR PET BEEN FASTED?* YES NOTIME OF LAST MEAL?*While hospitalized, if your pet suffers respiratory arrest (stops breathing) or cardiac arrest (the heart stops), we need to know your wishes concerning treatmentIf you would like us to resuscitate your pet, please initial this lineIf you would NOT like us to resuscitate (DNR) your pet, please initial this lineDate* MM slash DD slash YYYY Phone*Signature* *****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.*****CommentsThis field is for validation purposes and should be left unchanged.
