Client's Name *

First

Last

Email *

Pet's Name *

Ultrasound Procedure

The phone number where you can be reached TODAY is *

Note: In case of an emergency and/or prior to additional procedures, you will be contacted by telephone. Please keep your phone with you.

Other phone number where you can be reached TODAY is

The last time that my pet had any food before arriving was *

Ultrasounds at Rancho San Carlos Pet Clinic are done by a mobile service and not performed by our veterinarians. Abdominal ultrasonography is a non-invasive technique used to image organs within the abdomen and/or chest. 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 understand that my pet may require sedation in order to obtain diagnostic images and authorize the veterinarian to administer sedation if necessary. I understand this will incur an additional cost of $50-100.

In certain situations, additional diagnostics are recommended during an ultrasound. A fine needle aspiration is a procedure involving placement of a needle, using the guidance of an ultrasound, into an organ or mass. A tissue sample is drawn into the needle and sent in for diagnostic testing. This procedure is often the first step towards diagnosing abnormalitiesidentified on ultrasound examination. Fine needle aspiration is generally a safe procedure, but with any procedure there are always inherent risks. If the veterinarian deems a fine needle aspirate necessary:

I authorize fine needle aspirates recommended by the veterinarian and do not wish to be contacted prior to the aspirate. I understand this will incur additional costs (average $300-500).
wish to be contacted prior to the fine needle aspirate being performed. I understand this may delay diagnostic treatment and may require additional ultrasounds in the near future.

CPR Consent: Some patients requiring ultrasound have illness. In the event of a catastrophic emergency, please elect what life-saving measures you would like performed so that we may be inaccordance with your wishes:(these are at additional cost)

Do NOT perform CPR on my pet
Basic life support and CPR measures (chest compressions, artificial respiration)
Advanced life support and CPR measures (IV medications, fluids, etc)

Please acknowledge the following Information: I certify that I am the owner, or authorized agent for the owner, of the above pet. I authorize the doctor on duty and assistants to perform the above described procedures including administration of sedatives and/or anesthetics, as well as any necessary and appropriate medical, surgical, nursing, diagnostic, and/or emergency care for the above pet. I understand that Rancho San Carlos Pet Clinic is not a 24 hour hospital. Should an overnight stay be necessary, direct observation will not be available. If the above pet needs observation we recommend transfer to a 24 hour emergency hospital. I understand that I am assuming full financial responsibility for all services rendered at the time my pet is discharged from the hospital.

We place the highest priority on ensuring you feel comfortable with the plan for your pet’s care and fully understand the authorizations below above giving your consent. If you have any questions or need clarification on any of the choices, please contact the hospital so a medical team member can review the form with you prior to completing it. As always, thank you for entrusting us with your pet’s care!

Signature *

Print name *

First

Last

Date *

UltrasoundConsent Form

Ultrasound Consent Form

Ready to Visit Us?

Visit the Rancho San Carlos Pet Clinic

Have a Question?

Address

Contact

Hours

Emergency Resources