Ultrasound Consent Form Procedures are performed at the Durham

Falconbridge Animal Hospital
1401 W. NC Hwy54
Durham, NC 27707
919-403-5591
Village Veterinary Hospital
50150 Governors Dr.
Chapel Hill, NC 27517
www.FalconbridgeAnimal.com
919-967-4779
Ultrasound Consent Form
Client:
Date;
Phone:
Patient:
DOB:
Age:
Sex:
Species:
Breed:
Procedures are performed at the Durham Office
I hereby authorize Falconbridge Animal Hospital and its agents to perform an ultrasound on my
pet. I am aware that it is important that my pet remains very still during this procedure and it is
sometimes necessary to sedate pets to achieve this. I am aware that the doctor will have to make
this decision without contacting me but that reasonable means will be used to perform the
ultrasoimd without sedation. I understand the nature of the procedure and that there may be risk
involved. Further, no guarantee has been made as to results or cure.
I understand that in the event that additional procedures are deemed necessary, an attempt will
be made to reach me before proceeding, but I understand that the veterinarians are authorized to
perform any necessary procedures if they are unable to reach me.
I understand that current Wellness Exams, Distemper, and Rabies vaccines all required for
pets, as well as Parvo, Lepto, Bordetella and a Fecal Flotation (dogs only) before admission to
the hospital. For those pets not current, vaccines will be updated as long as it is deemed safe and
advisable by a veterinarian.
I certify that to the best of my knowledge my pet is free of all external parasites upon signing this
release. If parasites, such as fleas or ticks, are found, I understand that my animal will be treated
on admission for an additional cost.
Other services desired at additional cost: (Please check)
Nail trim ($16.00)
Anal Gland Expression ($24.00)
Microchip Identification ($46.00)
Ear Scope Evaluation ($38.00)
Other:
My pet has fasted for 12 hours:
Yes
No
My pet is on heartworm prevention:
Yes
No
Ultrasounds are performed by a mobile service and may be performed as early as 8:00 AM or as
late as 5:00 PM. Please plan to pick your pet up between 5:00 PM and 5:30 PM unless told
otherwise.
A basic ultrasound is $312 without sedation; sedation fees vary based on the individual needs of
patients. I understand that all charges are my responsibility and that payment is expected at the
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Falconbridge Animal Hospital
1401 W. NC Hwy 54
Durham, NC 27707
919-403-5591
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www.FalconbridgeAnimal.com
Village Veterinary Hospital
50150 Governors Dr.
Chapel Hill, NC 27517
919-967-4779
time of discharge.
^Falconbridge & Village Vets can use my pet's photos on www.falconbridgeanimal.com and
their Facebook pages. (Become our friend on Facebook!)
Signature of Owner or Agent
Best Contact Number Today
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Date signed
8/4/14 3:10 PM