Ultrasound consent form

Animal / Owner name:

Contact telephone number:

I give permission for ultrasound images obtained by NVi to be used for advertising and training purposes including on social media sites (all identification of pet, owner and veterinary surgery are removed) Yes / No

My pet has been starved for >12 hours (abdominal only)

Yes / No
I give consent for sedation to be administered (abdominal only) Yes / No
If it is deemed necessary, I give consent for tissue samples to be taken under sedation or general anaesthetic (abdominal only) (please circle ‘No’ if you wish to receive a phone call prior to tissue sampling) Yes / No

Abdominal ultrasound only: I understand that if my pet has not been starved, or if consent for sedation is not given, that this may prevent parts of the examination from being performed.  I understand that there is a low incidence of complications associated witd sedation / anaesthetics and all ultrasound-guided procedures, and that a successful diagnosis or outcome cannot be guaranteed.

I understand that hair will be shaved off over the area to be examined (see below) and I have no objection to this. (Please note that botd sides and the underneatd of your pet will be shaved.)

Abdomen
Abdominal Ultrasound
Heart Ultrasound
Heart Ultrasound

I have read the above information and hereby give consent for my pet to undergo an ultrasound examination.

Signed:

Date:

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