Ultrasound Consent Form

Please fill out ALL fields below before your pet's ultrasound 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. Time Pre-visit pharmaceuticals were given (if they were prescribed prior to this appointment)*
3. Medications my pet is on and last time given*
4. Previous issues under anesthetic (please elaborate)*
5. Health concerns the doctor should be aware of (please elaborate)*
We are performing an abdominal ultrasound on your pet today. In order to get a proper image, your pet’s fur will need to be shaved on its abdomen. Abnormalities of organs are sometimes found that would indicate the need for fine needle aspirates (FNA) to help determine a diagnosis. Some areas have very little pain sensation (i.e. liver, discrete masses, lymph nodes, spleen) and as such, a very cooperative patient may not need any sedation for aspiration of an abnormal tissue. On the other hand, some patients require sedation to keep them still during the procedure. If we do find abnormalities on the abdominal ultrasound that dictate the need for FNAs please indicate your choice by initialing ONE of the following:*
- Proceed with FNAs without any phone call, sedation is approved if needed (additional cost: FNA - $200, sedation costs based on species and weight).
- Please call to discuss findings prior to proceeding with FNAs. Please be advised we will attempt to call you at the number you provided above, please try to be available by phone.
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.
Should my pet have problems under sedation I would like:*
- 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
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 receives 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*
- 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 Suzanne Misiaszek DVM, her associate doctors, agents, employees, students and/ or representatives full and complete authority to perform the surgical procedure described as above
- 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
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

Ultrasound 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

Ultrasound 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