Ultrasound Consent Form in Reno, NV - Mountain View Animal Hospital & Holistic Pet Care

Name:*

First Last

Phone:*

Email*

Address:*

Street Address City State ZIP Code

Pets Name*

First

Pet's Age/DOB*

Pets Sex:*

Male Intact

Female Intact

Male Neutered

Female Spayed

Pets Breed:*

Thank you for entrusting Mountain View Animal Hospital and Holistic Pet Care to perform a diagnostic ultrasound. Ultrasonography is a non-invasive technique to image organs within the abdomen or chest. The area to be imaged must be shaved in order to provide adequate imaging, and minor irritation may occur to the skin as a consequence. Hair regrowth generally takes multiple weeks to occur but can be more prolonged in certain pets.

The ultrasound is performed by a third-party certified ultrasound technician. A nurse or assistant will phone when the testing is complete and will discharge your pet. The technician cannot legally provide any medical findings. Further, the results typically are not available on the same day as the ultrasound. The images are sent to a board-certified ultrasound radiologist and/or cardiologist for review. Your primary veterinarian will be contacting you with results and a treatment plan once the results from the radiologist are completed. The results take 2-4 business days unless they were sent STAT for an additional charge because of an emergency situation. The ultra-sonographer technician is not available for consultation with clients.

If indicated, fine needle aspiration is a procedure involving the placement of a needle, using the guidance of an ultrasound, into an organ or mass. A sample of tissue cells is drawn into the needle, placed on a slide, and sent to a diagnostic laboratory to look for cancer cells, inflammation, or other abnormalities. This procedure is often recommended if an abnormality is identified on ultrasound and is the first step towards diagnosing the nature of the abnormality. Some problems are easily diagnosed via fine needle aspiration, but others may not yield an answer via this technique. Fine needle aspiration is generally a safe procedure, but there is a small risk of significant bleeding from the organ or mass targeted. The risk is increased in patients that have a bleeding disorder and in certain cancerous masses but may also rarely occur in patients that were not considered to be at risk and may require intervention to stop or risk serious health complications. Fine needle aspirations would be performed by the attending doctor. Possible blood work to assess bleeding concerns is always recommended and can be performed the same day, prior to any aspirations at an additional cost.

Light sedation is typically necessary to perform the ultrasound, fine needle aspirations, and other diagnostic tests to receive accurate results and the clearest images, as even light panting can cause distorted images that may result in misinterpretation. Sedation usually only lasts a few hours, but some patients that are more sensitive can remain quiet until the following day. Rarely, depending on the type of sedation used, there may be a detrimental impact on blood pressure, heart rate, or breathing that could require intervention or risk serious health consequences. General anesthesia is usually never necessary.

Please initial if giving consent:

I consent to have an ultrasound performed on my pet by a certified ultrasound technician. I understand results will not be returned for typically 2 business days unless sent STAT for an extra fee.*

Initials

I consent to have fine needle aspirations performed on my pet if deemed indicated by the results of the ultrasound and accept additional costs. If aspiration is performed, a coagulation blood test (PT/PTT) will be performed prior at an additional cost. (if initially declined, a repeat visit *with a possible recheck ultrasound fee* can be scheduled)

Initials

I, the authorized owner, have read and understand everything stated above. I understand the results, unless an emergency and sent to the radiologist with an additional STAT fee, the results may take 2-4 business days to return. The attending doctor will call my primary phone number on file when received. I understand payment is required in full at the time of discharge.

Initials

Current Diet:

Last Fed:

Any additional information you would like to provide pertaining to your pets procedure today?

Authorization for Sedation

I have elected conscious sedation for your pet's procedure today. This sedation will be "light conscious sedation" where my pet will maintain protective reflexes, however, they will be less aware of their environment. I certify that I am the owner, or authorized agent of the owner, of the animal above and have full authority to execute this agreement. I also certify that I am 18 years of age or older. I authorize Mountain View Animal Hospital and Holistic Pet Care (MVAH & HPC), its veterinarians and employees under veterinary supervision, to perform the procedure(s) identified above. I understand that some risk always exists with sedative administration and invasive procedures and that during the performance of these/this procedure(s), conditions may be encountered that necessitate an extension of, or variance from, the procedure(s) set forth above. I have discussed the recommended procedure(s), associated risks, and anticipated recovery with an attending veterinarian. All questions and concerns I have about sedation, procedures, and associated risks have been answered to my satisfaction. I understand that a reasonable attempt will be made to contact me if expected fees will exceed the estimate by 15% or more. I agree to assume financial responsibility for all fees associated with the care of my pet and agree to provide payment in full, in accordance with the payment policy, at the time my pet is discharged. This consent will cover the next 12 months for any elective sedation procedures. I will notify the doctor if there are any changes in my pet’s health since the last sedation procedure.

CPR CONSENT AND RELEASE OF LEGAL LIABILITY

Based on the medical judgment of MVAH & HPC's veterinarian(s), should my pet require CPR, including cardiac compression, positive pressure respiration, emergency drugs, or other interventions, I request or decline that the doctor(s) at MVAH & HPC pursue such medical care as indicated below. Furthermore, I have been informed by the team at MVAH & HPC that less than 5% of animals that require CPR will survive to be discharged from the hospital. I understand that despite the best efforts of the veterinarians and the team members at MVAH & HPC, CPR may not allow my pet to regain his/her normal mental or physical capacity. Priced from $75-$150, charges are due in full upon pick up if CPR is performed. Regardless of whether I consent or decline to have CPR performed on my pet, in consideration for following my directive, I hereby waive, release and discharge any and all claims for damages, including, but not limited to, claims for death, injury, or property damage, whether or not resulting from the negligence, gross negligence or other acts of Mountain View Animal Hospital and Holistic Pet Care 6474 Bonde Lane Reno, NV 89511 775-853-6900 (phone); 775-853-6966 (fax) MVAH & HPC, its veterinarians and staff. I declare that any such veterinarian, staff, and MVAH & HPC is acting in accordance with my directions. This is intended to be an advance release of legal liability.*

I DO Consent for CPR

I DO NOT Consent for CPR

I, the owner of the patient(s), hereby authorize the veterinarians and staff of Mountain View Animal Hospital & Holistic Pet Care to examine, treat, and prescribe the necessary medication for the above-listed pet. This includes, but is not limited to, procedures therapeutically and/or diagnostically. I further understand that this facility has a doctor on staff between 7:30 am to 5:30 pm only, therefore, there is no continuous presence of doctors after regular business hours. I certify that all the information above is correct, that I am the rightful owner or authorized agent of this pet(s), and that I am at least 18 years of age. Mountain View Animal Hospital & Holistic Pet Care does not operate as an emergency hospital and although we will always try to be available, I understand I may be referred to an emergency hospital even during open hours if we feel it is best for my pet(s).

I understand by Nevada pharmaceutical law all prescriptions including herbals that leave the hospital are non-refundable.

*A complete treatment plan (estimate) may be supplied at any time for all services agreed upon by owner and hospital including sedation. I, the authorized owner, have read and understand everything stated above. I have been given the opportunity to be supplied with a complete treatment plan and agree to all charges. I understand payment is required in full at the time of discharge.

Owner Printed Name*

First Last

Owner Signature*

Date*

Mountain View Animal Hospital and Holistic Pet Care
6474 Bonde Lane Reno, NV 89511
775-853-6900 (phone); 775-853-6966 (fax)