Owner Information

Owner's name

Owner's address

Owner's phone number

Owner's email

Patient Information

Breed

Patient's name

* Species * SpeciesCanineFelineOther

Date of birth/age

* Sex * SexMMNFFS

Weight

Other:

Procedures Authorized: Procedures Authorized: Ultrasound Examination Sedation IV Catheter Placement Fine Needle Aspirate(s) Tru-cut Biopsy(ies)

Sedation and Monitoring, other procedures Sedation and Monitoring, other procedures I understand that an IV catheter will be placed and sedation will be administered, and my pet will be monitored throughout the procedure. I understand the risks of sedation/other procedures listed above. These have been explained to me verbally or in writing. Note: This does not constitute general anesthesia. If your pet requires general anesthesia (such as in case of needing a Tru-cut Biopsy), this will be discussed separately.

Consent Statements (Please check each box) :

Procedure Explanation and Expectation of communication: Procedure Explanation and Expectation of communication: I have been informed about the nature of the procedures listed above, including the benefits and potential risks. I understand that routine/non-urgent results will not be discussed with me by the radiologist or radiology staff. These results shall be directly transmitted to my family/referring veterinarian. I understand that in case of an unexpected diagnosis constituting an emergency, the radiologist or associated staff may advise for my pet to be seen by an emergency service I understand that a diagnostic test does not provide the guarantee of a definitive diagnosis of my pet’s condition. I understand that in case of uncooperative behavior of my pet despite best efforts (such as sedation), the test may not be performed. Unexpecting diagnosis constituting an emergency: Occasionally, patients that appear healthy may have serious underlying conditions (such as, internal organ hemorrhage) that are only identifiable through diagnostic tests such as ultrasound. In these cases, the radiologist may recommend that your pet be immediately taken to the emergency services at OAESH (subject to availability), your primary veterinarian, or another emergency veterinary facility. If you choose not to follow this recommendation, it will be documented as an action taken “Against Medical Advice (AMA).”

Financial Responsibility Financial Responsibility I accept responsibility for all charges incurred during these procedures.

Emergency Situations

Consent for CPR and Emergency Treatments: Consent for CPR and Emergency Treatments: I authorize the veterinary team to perform CPR and any other necessary emergency treatments to save my pet’s life. I understand this procedure itself can carry risks such as broken ribs, lung hemorrhage from compressions and it may ultimately not be successful in reviving my pet. I acknowledge that despite the outcome, there may be costs associated with it. Yes, I consent to CPR and emergency treatments.

Do Not Resuscitate (DNR) Directive: If you choose not to proceed with life-saving measures, please indicate below:

DNR Directive: DNR Directive: I understand that choosing not to perform CPR may result in my pet not surviving an emergency situation. I provide a Do Not Resuscitate (DNR) directive for my pet.

Owner Acknowledgment:

I have read and understand the information provided and give my consent for the above procedures and associated costs.

Owner Signature: (Please type full name)

Date