Client & Patient Details

Client Name *

Pet's Name *

Name of Contact for Today *

Best Contact Number for Today *

When was your pet's last meal? *

performed all the

Does your pet have any food allergies? If yes, what?

Current medications

Examination Consent

I consent to the following ultrasound examination being performed on the above patient *

If other, please specify *

Consent & Declarations

I understand that some level of sedation is usually required for the examination. The possible risks of this have been explained to me. Any further costs for sedation that apply have also been detailed (please note the cost of sedation is included for all abdominal, cardiac and bi-cavity examinations). *

I understand and agree

I consent to the collection of samples from any areas of interest identified during the examination (e.g. organs, nodules, lesions, fluid or urine), where the veterinarian performing the examination considers sampling to be diagnostically useful and safe to perform. Obtaining samples and analysis at external laboratories incurs additional fees per area sampled. *

Yes
No
Not Applicable

In some cases, assessment of blood-clotting times may be recommended or required before a needle sample is obtained, particularly when sampling the liver. This test can be performed in-house. Please select one of the following: *

I consent to the clotting test being performed if the veterinarian considers it necessary or strongly recommends it before sampling. I understand that this will incur an additional fee of $165.
I do not consent to the clotting test. I understand that, if testing is considered necessary before sampling, samples may not be obtained from identified nodules, lesions or other areas of interest.
N/A - Sampling not indicated

I understand that the patient's fur must be clipped for ultrasound examination. *

I understand and agree

I understand that this ultrasound examination is being carried out by a veterinary surgeon with extensive additional training and qualifications in veterinary ultrasound, not a specialist veterinary radiologist or cardiologist. *

I understand and agree

I understand that, with the exception of conditions requiring immediate attention (e.g. surgery), results of the examination will not be discussed with me at the time my pet is discharged. *

I understand and agree

I understand that I will need to speak with my regular vet regarding the ultrasound findings and to make a plan for my pet's immediate and ongoing care. *

I understand and agree

Education

PAUS may use anonymised information from interesting or educational cases for veterinary education and training. This may include information such as your pet's age, sex and breed, as well as ultrasound images, other diagnostic images and relevant clinical findings. Information that identifies you or your pet will not be included.

I understand and agree that anonymised information and diagnostic images from my pet's case may be used for veterinary education and training. *

I understand and agree

Photography & Marketing

From time to time, we may photograph or record patients while they are at PAUS and use this content on our website, social media pages or other PAUS marketing and communication platforms. You are welcome to say no without it affecting your pet's care.

I consent to my pet being photographed or recorded and this content being used by Perth Animal Ultrasound for marketing purposes. *

Yes
No

Financial Agreement

Estimated cost for procedure

To be filled in by admitting nurse

+/- Estimated cost for additional sampling

To be filled in by admitting nurse

Estimated Additional Cost

Please specify the maximum amount you consent to

Total

$0.00

I agree to settle my account balance IN FULL prior to my patient being discharged. *

I understand and agree

I would like to pay using GAP only *

N/A - Not Insured
No
Yes

Policy Holder Name *

Name of Insurance provider *

Policy Number *

Residential address for Policy *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Declaration & Signature

Full name of person signing *

Date *

Signature *

Clear Signature

Consent Form