Echocardiogram - Drop Off Consent Form

Please use this form to fill out ALL subject fields prior to your pets echocardiogram appointment.

Client (Owner) Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Pet Name*
Breed*
Color*
Age*
Please specify weeks/months/years*
- Weeks
- Months
- Years
Sex*
- Male
- Neutered Male
- Female
- Spayed Female
1. Time of last meal*
2. Medications my pet is on and last time given*
3. Health concerns we should be made aware of*
Consent*
- I have been offered pre-anesthetic bloodwork: Bloodwork checks kidney and liver enzymes. These blood tests will help us assess the health status of your pet more completely and determine if there are any additional precautions we need to take before surgery.
- I have declined pre-anesthetic bloodwork
Consent*
- An IV catheter placement is REQUIRED for all anesthetized/surgical patients regardless of age. This placement allows the veterinary staff to administer fluids to maintain hydration and blood pressure. This also allows us quick access to veins in case of an emergency situation. A small patch of fur will be shaved on either the forearm or the back legs in order to do so. This is not optional, it is a required protocol here at Tamarack Veterinary Clinic.
Consent*
- We are a Fear Free Certified Clinic that aims in reducing fear, anxiety and stress in our patients. If we notice that your pet is showing any signs of these, we automatically request that your pet gets some anti-anxiety/calming medication prior to their sedation. (Please be aware that you are responsible for the costs of this – it varies depending on weight of animal and breed.)
- I do not consent to Fear Free methods
Consent*
- We are performing an echocardiogram on your pet today. In order to get a proper image, your pet’s fur will need to be shaved (under the front legs, near the heart area).
- I do not consent to my pet's fur being shaved
Consent*
- I, the undersigned, do hereby certify that I am the owner (duly authorized agent for the owner) of the animal described above, that I do hereby give the attending veterinarian, her associate doctors, agents, employees, students and/ or representatives full and complete authority to perform the procedure(s) described as
- I do not provide consent to the doctors to perform the procedures as described above
Consent*
- FURTHERMORE, I UNDERSTAND THAT DURING THE PERFORMANCE OF THE PROCEDURE(S) THAT I HAVE AUTHORIZED, UNFORESEEN CONDITIONS MAY ARISE. THEREFORE, I HEREBY CONSENT TO AND AUTHORIZE THE PERFORMANCE OF SUCH PROCEDURES AS ARE NECESSARY IN THE EXERCISE OF THE VETERINARIANS PROFESSIONAL JUDGMENT. I ALSO DO HEREBY ACKNOWLEDGE THAT I UNDERSTAND THAT THERE ARE NO GUARANTEES EITHER EXPRESSED OR IMPLIED THAT THE PROCEDURES AUTHORIZED WILL BE WITHOUT COMPLICATIONS FROM UNEXPECTED EVENTS BEYOND THE VETERINARIANS AND HOSPITAL’S CONTROL.
- I do not consent to the unforeseen risks involved with this procedure
In such case, I authorize the following measures to be taken:*
- CPR initiated (I understand that I will be responsible for the costs of doing so. Can range from $300-$600. If CPR initiation is not successful, you are still responsible for the costs.)
- No CPR
Do you have pet insurance, if so, what company?*
Please list the policy number.*
Signature*
Date*
Date Format: MM slash DD slash YYYY
Best phone number to contact you during the time of appointment*

Have a Question? Need to book an appointment?

Connect with us and one of our team members will be happy to assist you.

CONTACT

2531 – 17th Street NW
Edmonton, AB
T6T 0Y2

Phone: 780-250-1700
Fax: 780-250-1705
Email: [email protected]

HOURS

Mon, Wed, Fri 8:00am -6:00 pm

Tues, Thurs 8:00 am -8:00pm

Closed Weekends and Holidays

Echocardiogram - Drop Off Consent Form

Have a Question? Need to book an appointment?

Connect with us and one of our team members will be happy to assist you.

CONTACT

2531 – 17th Street NW
Edmonton, AB
T6T 0Y2

Phone: 780-250-1700
Fax: 780-250-1705
Email: [email protected]

HOURS

EMERGENCIES

For after-hours please contact either:

Pulse Veterinary Specialists and Emergency
320-450 Ordze Rd Sherwood Park, AB
(780)-570-9999

VCA Guardian Veterinary Emergency and Specialist Centre (780) 436-5880

Contact Us

Echocardiogram - Drop Off Consent Form

Have a Question? Need to book an appointment?

Connect with us and one of our team members will be happy to assist you.

CONTACT

2531 – 17th Street NW Edmonton, AB T6T 0Y2

Phone: 780-250-1700 Fax: 780-250-1705 Email: [email protected]

HOURS

EMERGENCIES

For after-hours please contact either: Pulse Veterinary Specialists and Emergency 320-450 Ordze Rd Sherwood Park, AB (780)-570-9999

VCA Guardian Veterinary Emergency and Specialist Centre (780) 436-5880

Contact Us

2531 – 17th Street NW
Edmonton, AB
T6T 0Y2

Phone: 780-250-1700
Fax: 780-250-1705
Email: [email protected]

For after-hours please contact either:

Pulse Veterinary Specialists and Emergency
320-450 Ordze Rd Sherwood Park, AB
(780)-570-9999