Owner's Name *

First

Last

Phone *

Email *

Pet's Name *

Authorization to Provide Care *

I, the undersigned, certify that I am the owner, or an authorized agent for the owner, of the pet listed above and all other information is correct.

My pet is on the following medications:

Please include dose and route (e.g. 30 mg twice a day by mouth)

The last time my pet ate any food was: *

Nothing since midnight
Nothing since 6 am
Ate today
Other

If other, please specify *

Echocardiogram Information

An echocardiogram is a non-invasive technique used to examine the heart using an ultrasound machine. This procedure allows us to assess the structure and function of your pet's heart to diagnose or monitor heart disease. The chest area must be shaved in order to provide adequate imaging. Irritation may occur to the skin as a consequence. Hair regrowth generally takes multiple weeks but can be prolonged in certain pets. *

I have read and understand.

Authorization for Sedation

The best images usually require the need for sedation. If indicated by our veterinarian sonographer, your pet may require sedation in order to perform the echocardiogram. Sedation costs will be presented to you prior to your pet’s ultrasound and generally range between $50 - $150 depending on your pet's size and degree of sedation required. *

I have read and understand.

In the event that my pet requires sedation, do you authorize the administration of sedative medications? *

Yes
No

If no, please explain

In the event of a catastrophic emergency, please elect what life-saving measures you would like performed: (these are at additional cost) *

Do NOT perform CPR on my pet
Basic life support and CPR measures (up to $1000)
Advanced life support and CPR measures (in excess of $1000)

Authorization and Risk Assessment:

While Tell Tail Veterinary Urgent Care provides the highest quality of medical services, I understand the risks and understand that the veterinarians and hospital team will do everything possible to minimize any risks. I will not hold Tell Tail Veterinary Urgent Care, the veterinarians, or any team member liable for any complications that may arise. No warranty or guarantee has been stated or implied to me as to the results or cure afforded by these treatments or procedures. *

I understand that I am assuming full financial responsibility for all services rendered at the time my pet is discharged from the hospital.

Signature *

Clear Signature

Today's Date *

Echocardiogram Consent Form