Pet Parent Name *

First

Last

Pet Name *

Phone Number *

Email *

Ordered Request *

Has the patient fasted for 12 hours prior to the appointment? *

YES
NO

Last time that the patient had anything to eat *

Does the patient have any allergies or reactions to any medications? *

YES
NO

Is the patient currently taking medication, including over the counter and/or monthly preventative? *

YES
NO
NOT SURE

If recommended by the doctor, I authorize the following additional medical services to be performed

Blood Pressure
Bloodwork
Radiographs

In order to obtain proper imaging, your pet's fur will be shaved either on it's abdomen and/or chest dependent upon the procedure being performed today.

We make every effort to perform the ultrasound and/or echocardiogram procedures without using sedation. However, in certain circumstances sedation does become necessary. By signing the Ultrasound Admittance Form, you authorize the use of mild sedation for the safety of your pet. You will not be contacted if the use of mild sedation is necessary.

Ultrasound results take approximately 3-5 business days to return unless you request a STAT report, for an additional fee. Upon receiving ultrasound results, a doctor will contact you to discuss the findings.

Authorization and Risk Assessment:
I authorize Rocky Gorge Animal Hospital to perform the above veterinarian ordered ultrasound and/or echocardiogram for my pet. No warranty or guarantee has been given to me as to the results or cure afforded by these treatments or procedures. Additionally, I authorize Rocky Gorge Animal Hospital to perform additional diagnostic, treatment, or procedure(s) deemed necessary. While Rocky Gorge Animal Hospital provides the highest quality care, I understand that there are rare complications associated with any procedure.

I fully understand these risks and understand that the veterinarians and the hospital staff members will try to minimize such risks. I will not hold Rocky Gorge Animal Hospital, the veterinarians, or any staff members liable for any complications that may arise.

While your pet is in our care, we always want to be prepared with your wishes. In the event your pet should go into cardiac or respiratory arrest, we need to know how you would like us to proceed.

Your pet will not be admitted into the hospital unless one of the following options are selected below *

Perform CPR: including manual ventilation, chest compressions, and medications to restore cardiac rhythm. I understand I will incur all costs associated with CPR performance, regardless of the outcome.
Do NOT perform CPR (DNR): In the event that my pet stops breathing OR his/her heart stops beating, DO NOT attempt resuscitation or any further life saving measures.

YOUR SIGNATURE or YOUR AUTHORIZED AGENT'S SIGNATURE BELOW INDICATES THAT YOU HAVE READ AND FULLY UNDERSTAND THIS ULTRASOUND ADMITTANCE FORM AS WELL AS AUTHORIZE SHAVING AND LIGHT SEDATION, IF NEEDED TO OBTAIN PROPER IMAGING.

Initial to digitally sign this form and state that you have read and agree to the above *

My typed initials above certifies that I agree to be bound by the terms and conditions stated in this form.

Today's Date *

Dual Pre Ultrasound Form

Rocky Gorge Animal Hospital

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