Owner's Name: *

First

Last

Email: *

numbers potential list

Patient's Name: *

Please indicate which ultrasound/procedure your pet is being dropped off for: *

Abdominal
Echocardiogram (Heart)
Dual Cavity: Both Abdominal and Echocardiogram
Biopsy (PT/PTT screen must have been done within 24 hours)
Other (Specify)

Please specify: *

Are there any new symptoms since last visit? *

When was their last meal? *

Any Medications (Prescribed or Over the Counter) or Heartworm/Flea Prevention given. Please list & when given: *

Notice of Risk with Anesthesia:

Any veterinary service that required anesthesia poses a potential health risk to your pet. A current CBC/Chemistry Panel may identify some potential risk factors and/or ensure that your pet is in a lower risk category. Please choose one of the following: *

PT/PTT-Coagulation test (Required if biopsy is performed)
Comprehensive (CBC+12CARD+UA)
Has been completed within 30 days.
I decline the recommended WELLNESS CHECK at this time and request that you proceed with anesthesia. I understand that there is always a potential risk of death associated with the use of anesthesia

Authorization for testing and anesthetic risks: *

I understand that some risks always exist with anesthesia and/or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated. My submission of this form indicates that any questions I have regarding the surgical procedure and the anesthetic risks have been addressed and I understand and accept them.

Additional Comments (optional) Please list ALL phone numbers or pagers where you can be reached TODAY:

In the event it is determined that your pet(s) needs additional treatment, we will call you at the numbers indicated. If we are unable to reach you, we will follow the treatment option below. Choose an option: *

I trust your decision to perform any testing, treatment, or x-rays as deemed necessary for my pet’s health.
Call or text me first. If you cannot reach me, your may proceed with any procedure(s) deemed necessary.
Perform only the treatment authorized at time of drop off.

Please Note: It is difficult to give an estimate of charges when a patient is dropped off for treatment/emergency services. Please wait to discuss fees after the veterinarian has examined your pet and a discharge appt. has been made.

2. Blood Profile/CBC/Chemistry Panel *

The use of anesthesia poses a potential health risk to your pet. To decrease the risks associated with anesthesia, a current pre-anesthetic blood profile (CBC/Chemistry Panel) is highly recommended. A blood profile can rule out any pre-existing conditions that may not be evident physically, but could lead to serious complications. This profile includes tests that check for anemia, infection, diabetes, kidney/liver failure, and other potential underlying problems.
Please note that the fees for this blood work are in addition to the cost of the scheduled procedure. Also, immature pets, aged pets, and sick/debilitated pets are in a higher risk group and may need more extensive blood work than what is offered on this release form. If your pet is in this higher risk group, please discuss blood work fees with the Doctor.

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Today's Date *

Ultrasound Drop-Off Form

Ultrasound Drop Off Form

Notice of Risk with Anesthesia:

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