Ultrasound Consent Form

Please complete the following form before your visit!

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Ultrasound Consent Form

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Client’s Name: *

Pet’s name *

Email *

I hereby certify that I am the owner or an authorized agent of the owner and am over the age of eighteen.

Our goal is to provide a safe, stress-free experience for your pet while obtaining valuable diagnostics to develop an effective treatment plan. We will make sure their pet is comfortable during their stay and understand the stress of having them away from the family home for the day. To complete the ultrasound satisfactorily, please allow us to use our veterinary judgement and experience by consenting to the items below:

I understand why the ultrasound has been recommended. It has been made clear, that I will need to bring my pet named above to the Fitchburg Veterinary Hospital the morning the ultrasound has been scheduled between 7:40 a.m.-8:00 a.m. I will be informed of the date as soon as it is confirmed with the Ultrasonagrapher. I understand that the Ultrasonagrapher is not an employee of Fitchburg Veterinary Hospital and will not provide a specific time for this service; when the Ultrasonagrapher arrives at the clinic and performs the ultrasound is out of Fitchburg Veterinary Hospital’s control. *

I Understand

I understand I cannot be present for the procedure. Fitchburg Veterinary Hospital requires a deposit for the full cost of the ultrasoundin order to move forward with scheduling the procedure. I understand that the price for the ultrasound procedure does not include sedation and/or lab fees, if required. This deposit is non-refundable if I cancel my appointment less than 24 hours before the required drop off time of 8:00 a.m.on the day of the scheduled ultrasound. Fitchburg Veterinary Hospital will alert me once the procedure has been completed. *

I Understand

I do understand that the results may not be available on the same day the ultrasound is performed. I understand that the veterinarian in charge of my pet’s case will be contacting me as soon as possible. The Ultrasonographer is not available for consultation with clients. Ultrasonography is a non-invasive technique to image organs within the abdomen or chest. The area of my pet’s ultrasound will be shaved toallow adequate imaging. Minor irritation may occur to the skinas a consequence. Hair regrowth generally takes multiple weeks to occur butcan be more prolonged in certain pets. *

I Understand

Example of Shaved Abdomen

dog-lower abdomal

To enhance the ability of Fitchburg Veterinary Hospital to diagnose an abnormality found during the ultrasound examination, an ultrasound guided fine needle aspirate (FNA) or tissue core biopsy may be performed. In these cases, an ultrasound is used to guide a small needle into a suspected area of abnormal tissue to obtain cells or tissue for submission to our outside laboratory for analysis. A small amount of bleeding is common with fine needle aspiration and/or biopsy, usually with no further consequences. Severe bleeding seldom occurs but can rarely lead to serious complications requiring intervention. Therefore, these procedures will only be performed if required for proper diagnosis and treatment. In some cases, additional laboratory testing may be required prior to aspiration. Some problems are easily diagnosed via fine needle aspiration, but others may not yield an answer via this technique. Your pet will be evaluated and monitored carefully by your veterinarian before, during, and after these procedures to minimize the risk of serious complications from occurring.

Although rarely the case, my pet may need to bese dated to obtain a satisfactory quality diagnostic examination or to perform fine needle aspiration. Sedation, in rare instances can cause side effects such as a low or abnormal heart rate or breathing pattern. My pet will be monitored carefully by the team at Fitchburg Veterinary Hospital to minimize the risk of these complications from occurring.

Other Instructions:

Please call us prior to this date if there are any additional problems or concerns that you would like the doctor to address while your pet is in the hospital.
Please withhold your pet's food after 12:00 am prior to the exam
Continue to give your pet water as normal prior to the exam.
Please try to prevent your pet from urinating the morning of your appointment as a full bladder helps us visualize structures in and around the bladder. If the ultrasound will occur later in the day, we will walk your pet to ensure their comfort.
If your pet is taking any medication that you are uncertain should be given the day of the procedure, please call our office for advice
Give lots of extra hugs and kisses!

I acknowledge that I have read and understand the procedures and associated risks discussed above. Please initial below to indicate your consent:

I consent to have an ultrasound performedon my pet: cost estimate: $650-$980 *

I consent

I consent to have a fine needle aspirate or core biopsy performed on my pet if indicated by the results of the ultrasound. (If initially declined, a repeat visit can be scheduled for these procedures, but at additional cost).Cost estimate: starting at $150 per FNA site *

I consent

I consent to the administration of sedation to my pet, if necessary. I understand that sedation will be administered by my regular veterinarian. (If initially declined, procedures may not be able to be performed at this time. A repeat visit can bescheduled for these procedures, but at additional cost). Cost estimate: $200-400 *

I consent

My pet has not eaten since 12:00 a.m. this morning *

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Signature of Owner or Authorized Agent

Clear Signature

Date :

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Ultrasound Consent Form

Ultrasound Consent Form

Example of Shaved Abdomen

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