Ultrasound Consent Form

Tech Initials

Owner

Client Number

Phone

Contact Email

Patient Name

Species

Breed

Age

Color

Sex

I am either the owner of or responsible for said pet and have the authority to give this consent. I am at least 18 years of age. By initialing, I am agreeing that have an ultrasound performed. I agree to indemnify and hold the Scottsdale Veterinary Clinic and its employees harmless from and against any and all liability arising out of the performance of any of the procedures referred here.

I hereby authorize the performance of a Diagnostic Ultrasound. I understand the cost of an Ultrasound Diagnostic is $400.65. I understand that if a current exam with TSVC is not on file, there will be an exam fee of $82.00 in addition to the cost of the diagnostic ultrasound. An Ultrasound Radiology Consultation Report may be required pending the doctor’s evaluation of the ultrasound, which would be a cost of $288.65 if found necessary.

I expect The Scottsdale Veterinary Clinic to use reasonable care and judgment while performing an Ultrasound Diagnostic. If it is found that sedation or anesthesia is necessary for my pet, I choose ONE of the options below:

Is your pet on any medications/dietary supplements? If so, please list medications below and why

How is your pet doing? Eating & Drinking? Vomiting? Comments:

Phone number where I can be reached today

Other Phone

Signature of Responsible Party

Sign above

If Not Owner, Print Name

Date

Ultrasound Consent Form

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