Ultrasound/Sedation Consent Form - Preston Animal Hospital : Preston Animal Hospital

Owner name*

First Last

Client ID*

Animal Last Name*

Breed*

Age*

Sex*

Last meal eaten*

Special diet or dietary restrictions

Current medications and time last administered

Please list any known drug allergies or adverse reactions to medication(s)

Ultrasound to be performed*

(NOTE: Any pet undergoing an ultrasound may be shaved at the corresponding site.)

SEDATION AND ADDITIONAL PROCEDURES: Sedation may be required to complete your pet’s ultrasound or may be required if needle aspirates of certain tissues are necessary.

Please choose one*

I authorize Gentle Care Animal Hospital to administer sedation and any needle aspirates that are deemed necessary.
I authorize Gentle Care Animal Hospital to administer sedation but wish to be called if needle aspirates are deemed necessary.
I wish to be called prior to my pet receiving any sedation.

*

I understand that if I cannot be reached by phone within 5 minutes I will have to schedule the recommended procedure or ultrasound for another time.

*

I understand that even with excellent care and precautions, rare adverse reactions or events can occur with sedation. These events are extremely rare and can include but are not limited to: cardiac arrest, respiratory arrest, and death.

*

understand that if sedation is needed an IV catheter may be placed and a small area on the leg will be shaved for placement.

MICROCHIP: Would you like your pet to have a microchip placed while sedated? ($66.40 with surgery)*

Yes
No
Already have one

Phone number where you can be reached between 8:30 a.m. and 3:30 p.m.*

Please provide email address or cell number if you would also like an email or text update when your pet is awake

Signature*