Name *

Pet Name *

Date *

We will need to be able to contact you or someone with permission to make medical and financial decisions.

Who will we be speaking with today?

Me
Someone else

If someone else, what's their name? *

1st Phone *

2nd Phone:

Car Make, Model, and Color that you will arrive/arrived in *

PLEASE ANSWER THE FOLLOWING QUESTIONS

When did your pet last eat? *

Last Drink? *

Is your pet currently taking any medication? *

Yes
No

If yes, list medication & last dose given

Has your pet had an adverse reaction to any medications (including sedatives or anesthesia)? *

Yes
No

If yes, what?

CONSENT

Echocardiogram/Abdominal Ultrasonography is a non-invasive technique used to image organs within the abdomen. 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. *

I give consent to shave any area required and understand that irritation to the skin can occur.

Your pet may require sedation in order to obtain diagnostic images and authorize the veterinarian to administer sedation if necessary. Your pet must be fasted for 12 hours before sedation. If you would like for your pet to be fed directly after the imaging is performed please bring a portioned amount of food with them. *Please note that if your pet requires sedation you will incur an additional cost. This price will be listed in your estimate* *

I give consent to sedate my pet if necessary.
I declined sedation and understand that if sedation is necessary the ultrasound will not be performed.

The echocardiogram/ultrasound images are submitted to the Radiologist/Cardiologist via telemedicine. This means we perform the ultrasound/echo then submit the images for review. In order to submit the images we have to wait for the assisting Sonographer to approve the images to be submitted. This can be a lengthy process so unfortunately we cannot give an accurate time frame for pickup and completion. *

I understand that my pet may have to stay until the end of the business day.
I decline leaving my pet until the end of the business day and understand the ultrasound will not be performed.

ADDITIONAL DIAGNOSTICS REQUESTED

Full Chem/CBC/Lytes - $145
Partial Chem and CBC - $95
Radiographs (2 views) - $150
Urinalysis - $55

Full Chem/CBC/Lytes - $145

Full blood work an all major organs, full red and white blood cell count, and electrolytes.

Indicated for longer anesthetic procedures and sick patients.

**Required for pets over the age of 8 years old**

*** Note – We may require this blood work for some procedures and situations

Partial Chem and CBC - $95

Basic internal organ screen (liver, kidneys) with full red and white blood cell count.

For generally healthy, younger patients.

**Required for pets over the age of 5 years old**

Radiographs (2 views) - $150

Urinalysis - $55

**Please note: If ultrasound is needed to obtain a urine sample you will be charged an additional $25.00. **

CPR Consent: I, the owner/agent understand that the therapeutic, anesthetic, or surgical procedures provided for my pet today involve the risk of complications, injuries, or even death, from both known and unknown causes. Should my pet require cardiopulmonary resuscitation (CPR), including cardiac compressions, positive pressure respiration, emergency medications, and other heroic interventions, I request that the doctor(s), staff, and Island Pet Veterinary conduct/do not conduct such medical care as indicated below. If I request said emergency procedures, I agree to be held financially responsible for veterinary services provided to my pet while staff members try to reach me for further directions. Regardless of my pet’s recovery or survival, I agree to pay CPR fees in addition to other fees already identified by the practice and agreed upon by me. *We will administer CPR treatment unless declined. *

I accept
I decline

I, the owner/agent for the pet described above, request and authorize an ultrasound for my pet. I have read and understand all of the information on this form. I understand that the staff at Island Pet Veterinary will contact me at the number listed above after the ultrasound is complete. *

I understand payment is due when my pet is discharged. I accept financial responsibility for charges incurred for this pet.

Signature *

Clear Signature

Ultrasound Form

We can’t wait to see you!

CONSENT