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Blood Glucose Curve Day Stay Waiver and Consent Form

Your pet has been scheduled to stay at our clinic for the day in order to undergo a blood glucose curve test, which involves taking multiple blood samples over several hours to monitor glucose levels and evaluate the effectiveness of insulin therapy. It is very important that all questions be answered as accurately as possible to allow your veterinary health care team to properly manage your pet's condition. Please complete the information below:

Date of Procedure

CLIENT DETAILS

First name ^*

Last name ^*

Email ^*

Phone ^*

Address ^*

ANIMAL DETAILS

Animal name ^*

Animal species ^*

Select Dog Cat Bird Guinea Pig Reptile Rabbit Horse Other

Animal breed ^*

Animal gender (e.g. male, female, unknown) ^*

Select Female Male Unknown

Desexed ^*

Select Yes No

Animal DoB or age ^*

insulin details

Why Feeding and Insulin Details Matter for a Blood Glucose Curve To get accurate results during your pet’s blood glucose curve, we need to know exactly what they ate and when, and if/when insulin was given. This helps us understand how your pet’s body is responding to insulin throughout the day. Even small changes like a skipped meal, a late dose, or giving a treat can dramatically impact blood sugar levels and skew the curve. If we don’t know what your pet ate or what insulin dose they received, we could end up with results that aren’t helpful (or worse, misleading) which could lead to unnecessary changes in treatment. Providing accurate feeding and insulin information gives us the best chance at safely fine-tuning your pet’s diabetes management and keeping them feeling their best.

Has your pet eaten a meal this morning?^*

Yes

No - IMPORTANT: If your pet did not eat their normal meal or missed their insulin dose, it may not be safe or useful to perform the glucose curve today. If you have made special arrangements with the veterinarian, please continue ahead. If you did not and are unsure how to proceed, please contact our clinic immediately for further instructions.

What time was the meal eaten (please be specific)? ^*

How much did your pet eat (exact measurement is not required but would be helpful)? ^*

What is the name of the diet you feed your pet? ^*

Did your pet eat anything outside of their normal diet in the last 24 hours. This includes treats, table food, dropped snacks, or mystery snacks from the yard?^*

Yes

No

If you answered yes, please describe what your pet ate, how much, and what time:

Did your pet receive insulin this morning?^*

Yes

No - IMPORTANT: If your pet did not eat their normal meal or missed their insulin dose, it may not be safe or useful to perform the glucose curve today. If you have made special arrangements with the veterinarian, please continue ahead. If you did not and are unsure how to proceed, please contact our clinic immediately for further instructions.

Has not been prescribed

What type of insulin is your pet getting?^*

Vetsulin

Prozinc

Other

If you answered other, please write in the name below:

What time was it administered (please be specific)? ^*

How many units were administered? ^*

Did you give your pet any medications/supplements today?^*

Yes

No

Some medications or supplements may interfere with the results of the testing so please be specific. Type N/A if no other medications were given.

Name of medication/supplement, how much given, what time given, notes: ^*

Name of medication/supplement, how much given, what time given, notes: ^*

Name of medication/supplement, how much given, what time given, notes: ^*

Name of medication/supplement, how much given, what time given, notes: ^*

Any NEW changes or concerns the vet should know about since last visit?^*

Yes

No

Please describe any new changes or concerns you have noticed since the last visit: ^*

Do you have any specific questions for the vet?^*

Yes

No

Please list your questions here ^*

Consent for CPR or DNR

CPR- Cardio Pulmonary Resuscitation is the treatment provided for a pet who has stopped breathing or whose heart has stopped beating. Resuscitation of a pet who has stopped breathing (but still has a heartbeat) is more likely to be successful than a pet who has no heartbeat. DNR- Do Not Resuscitate means that if a pet stops breathing or his/her heart has stopped, no effort should be made by our veterinary professionals to attempt to revive the pet, and the pet will be allowed to die.

In the event of a medical crisis:^*

I wish for the doctors of Midvalley Animal Clinic to perform CPR on my pet if he/she suffers respiratory or cardiac arrest. I understand that my pet may or may not respond to this life-saving procedure. I understand that if my pet survives because of CPR, he/she may have permanent health issues. I understand that CPR may cost up to $1,000.00

I DO NOT want CPR performed on my pet. I understand that if my pet stops breathing, and/or his/her heart stops beating, my pet will die. I elect to have DNR orders in place.

waiver

I am the owner/authorized agent of the pet presented for care. ^*

I understand the purpose of the blood glucose curve is to help evaluate and adjust my pet’s insulin dosage in order to manage their diabetes safely and effectively. ^*

I understand that my pet will remain at the clinic for several hours (typically 6–10 hours) and that multiple blood samples will be drawn during this time. ^*

I understand that small areas of my pet’s fur may need to be shaved to allow safe and clear access to the veins. Because multiple blood samples are collected throughout the day, my pet may have multiple blood-draw sites, which may include more than one leg and/or the neck. Mild bruising, tenderness, redness, or irritation may occur at these sites.

I acknowledge that some animals may become stressed in a hospital environment, which may influence blood glucose readings. I understand the veterinary team will do their best to minimize stress and obtain accurate results. ^*

I understand that while this is a low-risk procedure, there is always a possibility of minor side effects such as bruising at the blood draw sites, stress-related symptoms, or mild hypoglycemia/hyperglycemia fluctuations. ^*

I understand that an estimate of charges was given, the estimate is only an approximation and that unforeseen circumstances may result in final charges may be substantially greater than the estimate. I understand that any estimate given is in additional to any doctor consultation and treatments performed. ^*

I authorize Midvalley Animal Clinic to do the preceding services on my pet. I understand the following (1) No guarantee of successful outcome of treatment is either expressed or implied. (2) Risks are involved in the treatment of any condition including death. ^*

I understand all fees for services are payable by cash, check, or credit card and are due at the time services are rendered. I understand that any past due accounts are subject to all costs of collection, including legal fees. ^*

signature

By signing below, I confirm that I have read and understood this waiver and give consent for my pet to stay at the clinic for a blood glucose curve.

Please sign here^*

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AMENDMENT

Amendment Description *
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I, the undersigned, acknowledge that I have read and understood this amendment, which has been fully explained to me, and that it modifies the original consent form to which it is attached. I confirm that all information provided is accurate and that I consent to the changes outlined in this amendment. I understand that this amendment is part of the original consent form.

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Full name *
Amendment date *
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