Forms

Ultrasound Informed Consent Form

Please complete this consent form before your pet's scheduled ultrasound appointment.

Patient & Owner Details

Fields marked with * are required.

Legal Owner Name *

First *

Last *

Patient Name *

Last Meal Time *

Last Drink Time *

Best number to reach you at today *

Secondary Number

Is your pet on any medications? If yes, please list below. *

Informed Consent

Please mark the box in front of each statement in the space provided

I, the undersigned, owner or responsible party of the admitted patient, hereby authorize the Doctors of Edmonton West Animal Hospital & Spay/Neuter Centre (and whomever they may designate as assistants) to administer such treatments as diagnostically necessary as indicated by findings during medical evaluation.*

Sedation Authorization

To obtain high-quality diagnostic images, your pet must remain still during the ultrasound. If this is not tolerated, sedation may be required. Please select one statement below.

I understand and accept that there is inherent risk associated with any type of sedation, including death of the patient, and I authorize the Doctors of Edmonton West Animal Hospital & Spay/Neuter Centre (and whomever they may designate as assistants) to administer such treatments as necessary.I do not want my pet to be sedated, and understand and acknowledge that the ultrasound may not be able to be completed. I accept that I may be charged for the ultrasonographer travel fee as well as any partial charges for the incomplete ultrasound.

Tissue Sampling Authorization

If the ultrasonographer finds a mass, tumour, or area of concern, tissue sampling such as a fine needle aspirate or biopsy may be recommended. Please select one statement below.

I authorize the attending ultrasonographer to proceed with any tissue sampling that may be recommended, and take full financial responsibility for the associated additional costs ($405.54 for collection and laboratory analysis) where applicable.I prefer not to have any sampling done. I understand that if I change my mind later, the ultrasound will need to be repeated at additional cost, and that a definitive diagnosis may not be possible without recommended laboratory testing.

Additional Work & Authorization

I understand that when further, unforeseen work of a non-emergency nature is required, every attempt will be made to contact me by phone to discuss the case. If contact cannot be made in a timely manner, no additional work will be performed until informed verbal or written consent is obtained.*

I certify that I have read and fully understand the above authorization for medical and/or surgical treatment, and that the procedure has been explained to my satisfaction. I understand that no guarantee has been made regarding the results, that complications may require additional veterinary care or medication, and I assume full financial responsibility for all charges incurred for this patient.*

Signature *

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Verify you are human *