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Ultrasound Drop Off Form

Owner's information form

First name ^*

Last name ^*

Address ^*

Email ^*

Phone ^*

Phone Number (where you can be reached today): ^*

Appointment date time ^*

patient's information

Animal Name ^*

Patient weight

Animal species ^*

Select Dog Cat Bird Guinea Pig Reptile Rabbit Horse Other

Animal breed ^*

Patient color

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

Select Female Male Unknown

Animal DoB or age ^*

Name of veterinarian seeing seeing your pet: ^*

Which veterinarian has been your pet been seeing for this issue:^*

Dr. Zoe Braun

Dr. Paul Haderlie

Dr. Anna Rush

Dr. Cameron Rodee

Dr. Joseph Baker

Dr. Amy Anderson

Dr. Holly Black

Other

Write name of doctor that was not listed:

Mobile Ultrasound Specialist Schedule

Our ultrasound procedures are performed by traveling specialists who service multiple clinics throughout the valley. Because their arrival time depends on their travel route and the needs of patients at other locations, we cannot provide a specific time for your pet's procedure. Drop-Off: Please ensure your pet is dropped off between 7:00 - 8:00am. Duration: Your pet may need to stay with us for the entire day. Plan to pick up by 5:00 pm at the latest. Communication: Our staff will call you with an update and a pickup time as soon as the specialist has completed the scan and the veterinarian has reviewed the preliminary findings.

Select option to agree to terms^*

Yes - I understand that my pet is being dropped off for the day and the exact time of the procedure is subject to the specialist's arrival.

For certain cases, your veterinarian will require that you give your pet a sedative medication prior to arrival to your appointment. This medication would have been prescribed a head of time. If you're vet didn't prescribe any sedatives, mark no. Please confirm if your pet received a sedative medication this morning?

Yes

No

Please select the sedative(s):

Trazodone

Gabapentin

Acepromazine (Dogs)

Has your pet eaten a meal this morning?^*

Yes - You may need to reschedule unless previously approved with the veterinarian. Please speak to the front desk staff immediately if this is the case and be sure to indicate to them how much your pet ate. Fasting is important as a full stomach will make imaging organs around the stomach difficult or impossible (liver, adrenals etc). If your pet drank water, that is permitted.

No

Is your pet taking any medications or supplements routinely?^*

Yes

No

If yes, please list the name of the medication/supplement and what time it was last given. If no, skip to next question.

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. If no, skip to next question

I am the owner/authorized agent of the pet presented for care. 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 understand that my pet will be given a mild sedative during the ultrasound testing and under the direct supervision of a doctor. I understand that my pet will be shaved to allow the ultrasonographer to properly assess my pet during the procedure. I understand that my pet may have an IV catheter placed for this procedure. I authorize Midvalley Animal Clinic to do the preceding services on my pet. I understand the following: No guarantee of successful outcome of treatment is either expressed or implied. 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.^*

Yes - I understand the above and agree to proceed with the ultrasound procedure.

Please sign here^*

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AMENDMENT

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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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