Ultrasound Procedure & Sedation Release

Date *

Client Name *

First

Last

Email *

Pet's Name *

Ultrasound frequently requires shaving your pet (chest or abdomen or both). I understand my pet my be shaved. (Please Initial) *

Ultrasound requires that your pet has been fasted for 8-12 hours. My pet was fasted. (Please Initial) *

The last time (s)he ate was: *

Is your pet on any medication? *

Yes
No

Medication Name *

Medication Dosage *

Medication Frequency *

When was the last dose given? *

When is the next dose due? *

Add another medication? *

Yes
No

Medication Name *

Medication Dosage *

Medication Frequency *

When was the last dose given? *

Add another medication? *

Yes
No

Medication Name *

Medication Dosage *

Medication Frequency *

When was the last dose given? *

When is the next dose due? *

Add another medication? *

Yes
No

Medication Name *

Medication Dosage *

Medication Frequency *

When was the last dose given? *

When is the next dose due? *

Most pets do not require sedation for a diagnostic ultrasound. In some situations, sedation may be required due to patient discomfort, tense abdominal muscles, or aggression during the procedure. If sedation is required, your DVM will use medications that they deem suitable and safe for your pet and the procedure. Your DVM may require pre-anesthetic blood work prior to sedation. This should be discussed with your DVM prior to the date of the ultrasound. Please select one of the following options: *

YES, I authorize sedation if necessary for my pet at an additional fee.
NO, I do not authorize sedation for my pet. I understand that there may be a cancellation fee associated if the scan cannot be performed without sedation.

Please complete this form before your visit.

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