Ultrasound Consent Form Procedures are performed at the Durham



Ultrasound Consent Form Procedures are performed at the Durham
Falconbridge Animal Hospital
1401 W. NC Hwy54
Durham, NC 27707
Village Veterinary Hospital
50150 Governors Dr.
Chapel Hill, NC 27517
Ultrasound Consent Form
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)
My pet has fasted for 12 hours:
My pet is on heartworm prevention:
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
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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8/4/14 3:10 PM
Falconbridge Animal Hospital
1401 W. NC Hwy 54
Durham, NC 27707
'J ^ /
Village Veterinary Hospital
50150 Governors Dr.
Chapel Hill, NC 27517
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

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