Ultrasound Authorization FormOwner InformationName(Required) First Last Work Phone(Required)Cell Phone(Required)Other Phone(Required)Email(Required) Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Emergency ContactEmergency Contact NameEmergency Contact PhonePet InformationPet's NameBreedColorSexAgeWeightAuthorizationYour pet is having an ultrasound or echocardiogram examination today. The ultrasound examination will be done to look for any abnormalities in your pet. We recommend that you drop your pet off while the ultrasound is being performed. You will not be in the room during the ultrasound. If your pet is having an abdominal ultrasound, the hair on the abdomen will be shaved. If your pet is having a cardiac ultrasound (echocardiogram), there will be a small patch of shaved hair on both sides of his/her chest. Some pets may become itchy after the hair has been clipped; if you find that your pet is scratching a lot at home you can apply gentle moisturizers like aloe or an oatmeal- based shampoo/lotion. Occasionally, sedation (not general anesthesia) is necessary in order to complete the examination. We always attempt to perform ultrasound examinations without sedation and most of the time sedation is not necessary. Sometimes pets are very tense, anxious, or aggressive and sedation is required, both for their comfort and safety and for the safety of the staff holding the pet. If sedation is required, the doctor will use a light sedative that is either reversible or wears off in a few hours.Sedation Authorization I authorize sedation for my pet I DO NOT authorize sedation for my petWhen abnormalities are seen on the ultrasound examination (examples include enlarged lymph nodes and tumors), then an aspirate or biopsy of that abnormality may be taken. An aspirate or biopsy is when a small sample of tissue is taken with a needle. An ultrasound guided needle aspirate is a useful tool in obtaining information about these abnormalities. If appropriate, the doctor may use a small needle to obtain a sample of cells from an abnormal area that can be examined in the clinic or can be sent out to a pathologist for evaluation. This is a safe procedure that carries a very low risk of bleeding from the site of aspiration. Aspirations are only performed under sedation for comfort and safety.Fine Needle Aspirate Authorization I authorize fine needle aspirate for my pet I DO NOT authorize fine needle aspirate for my petI am the owner (or authorized agent of the owner) of the animal described above, and have the authority to execute this consent. I understand that some risk always exists with sedation, even in apparently healthy animals, including the possibility of death. I have discussed my concerns with the veterinarian and understand that it may be necessary to provide additional medical or surgical treatment to my pet in the event of unforeseen circumstances. I realize that no guarantee, legal or ethical, can be made to me regarding the outcome of any procedure performed. I hereby authorize the use of sedatives and other medications, as well as any such additional treatment, as deemed necessary by the veterinarian. I understand that hospital personnel will be employed in treating my pet. I have carefully read, and fully understand, this consent. The fees associated with these services have been explained to me, and I agree to pay such fees at the time my pet is released from the hospital.Signature(Required)CAPTCHAΔ
