InstagramThis field is for validation purposes and should be left unchanged.Practice Name*Pet Name*Client Name*Client Phone Number (must be reachable or provide alternative number)*I give permission to have an ultrasound performed on my pet. Yes No Ultrasound requires that your pet has been fasted for 8-12 hours, except if your pet is a diabetic. Further discuss this with your veterinarian if your pet is a diabetic. Has you pet eaten any food in the past 8-12 hours? Yes No, I understand that not fasting my pet may inhibit visibility of certain organs. I understand that my pet must be shaved for the ultrasound and/or procedure requested. I give permission to shave my pet (Chest/Abdomen, mass, thyroid, joint).* Yes No, I understand that not shaving my pet will likely inhibit the visibility of certain organs and limit our ability to obtain a diagnosis. Diagnostic ultrasound is non-invasive and low stress for most animals. However, each pet is an individual. If deemed by the sonographer and/or your pet's veterinarian that sedation will be helpful or needed (due to stress, excitement, anxiety, fear, aggression, or pain). In some cases, bloodwork may be needed prior to sedation. This should be discussed with your veterinarian prior to the date of ultrasound.* Yes, I authorize sedation if necessary for my pet at an additional fee. No, I do not authorize sedation for my pet. I understand that this may result in a limited ultrasound and impact the diagnostic value of the ultrasound or may result in canceling the ultrasound with a cancellation fee. During the ultrasound, if abnormalities are noted (mass or changes to organs), sampling of these abnormal tissues/structures may be indicated or recommended. This is usually in the form of a fine needle aspirate. Pre-sampling bloodwork and sedation will be required. This should be discussed with your veterinarian prior to the date of ultrasound. Sampling the tissues can help to reach a more definitive diagnosis.* Yes, I authorize fine needle aspiration if deemed necessary. This will be an additional cost of $35 per site. Additional costs will be added by your veterinarian for the samples to be sent for cytology/pathology review. No, I do not authorize sampling. If significant pathology is identified on ultrasound, the ultrasound report may be upgraded to STAT. This adds typically increases the cost of the imaging starting at least $50 to $100 to the cost.* Yes, I accept that there will be a higher fee for a STAT (emergency) consult and agree to pay if the doctor feels that need is urgent. No, I do not authorize STAT consultation for my pet and understand that it will be at least 1-2 business days to receive the final report. If significant fluid is seen in the abdomen or chest, drainage of that fluid may be recommended. You will be contacted regarding this procedure and associated benefits, risks and costs will be discussed.* Yes, I agree to let the doctor proceed with emergency procedures to alleviate my pet's suffering if indicated on the ultrasound. I understand I will be contacted with this finding prior to the doctor proceeding to discuss the need and estimated cost. No, I do not want my pet to receive ANY treatments without my prior approval and that this decision limits any immediate life-saving procedures to be done until I am contacted. This may result in my pet passing away if the situation is severe enough.