Ultrasound Informed Consent Form -

Legal Owner Name*

First Last

Patient Name*

Last Meal Time*

Last Drink Time*

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

Best number to reach you at today*

Secondary number

PLEASE MARK THE BOX IN FRONT OF EACH STATEMENT IN THE SPACE PROVIDED

Consent*

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.

In order to obtain high-quality, diagnostic images, your pet will be required to remain still during the ultrasound. In some cases, this will not be tolerated by the pet, and s/he will need to be sedated. Please read and initial one of the following statements:*

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. OR...
I do not want my pet to be sedated, and understand and acknowledge that the ultrasound may not be able to be completed. Further, I accept that I may be charged for the ultrasonographer travel fee as well as any partial charges for the incomplete ultrasound.

In the event the ultrasonographer finds any masses/tumors/questionable areas of interest, the ultrasonographer may recommend sampling of this tissue (e.g. fine needle aspirate, or biopsy). If your pet requires sampling , please read and initial one of the following statements*

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/if applicable. OR...
I prefer NOT to have any sampling done, and understand that if I change my mind at a later date, the ultrasound will need to be repeated at additional cost. I also understand that a definitive diagnosis MAY not be able to be reached if I decline recommended laboratory testing.

Consent*

I understand that in cases where further, unforeseen work is required and is of non-emergency nature (additional diagnostics, changes to treatment plans, etc), every attempt will be made by the veterinarians/staff to contact the owner by phone to discuss the case. I also understand, if contact cannot be made in a timely manner, no additional work will be performed until informed verbal or written consent can be obtained.

Consent*

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

Total Estimated Fee (+ GST)*

Type of Ultrasound