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? *

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 sampling of any identified areas of interest (e.g. organs, nodules, lesions, fluid, urine, or other), if the vet performing the examination believes it to be necessary or useful for diagnostic purposes, and safe to perform. Obtaining aspirates and analysis by an external lab incurs additional fees. *

Yes
No
Not Applicable

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

is photographed my

Education & Marketing

Occasionally, cases may be used for education or marketing purposes. We would like to ask your permission for the following — you are welcome to say no to any or all of these without it affecting your pet's care.

I consent to the collection of anonymised information of the patient (e.g., age, sex, breed) and information from their ultrasound to be used for educational purposes. *

Yes
No

I consent to my pet being photographed for the above purposes. *

Yes
No

I consent to my pet being featured on the Perth Animal Ultrasound website, Facebook page and other marketing platforms. *

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

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 *

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