Date *

Name *

First

Last

Email *

Confirm the type(s) of ultrasound to be performed on your pet today *

Abdominal Ultrasound ($320)
Urinary Ultrasound (kidneys and bladder only - $170
Pregnancy Ultrasound ($160)
Sterile urine collection via ultrasound-guided cystocentesis ($38 + $249.64 for the urine culture and sensitivity)
Echocardiogram (includes echo procedure + consult on images by cardiologist) ($425)
Urgent Ultrasound (Additional Fee of $75)

For the ultrasound images to be of optimal quality, your pet's hair will be shaved which can include the entire ventral abdomen as well as a small amount up the side of the abdomen to view the kidneys (on abdominal ultrasounds) or a square of the chest behind the armpits (echocardiograms). We will not shave more hair than necessary.

It is imperative that your pet remain still during the ultrasound exam. Depending on patient cooperation, sedation may be needed for this ultrasound procedure. Each patient is evaluated for the need of sedation depending on their cooperation level and type of ultrasound examination. Please be aware that if sedation is needed but declined, the ultrasound may not be able to be performed. You may elect to have your pet’s bloodwork evaluated prior to sedation as well.

Please accept or decline sedation for your pet. *

Decline sedation
Accept sedation ($56-86)

Please accept or decline pre-sedation bloodwork for your pet: *

Decline blood work
Accept blood work ($79 - Chem10 only)
Bloodwork already performed

On what date?

I understand that ultrasound is a noninvasive and useful diagnostic tool but there are cases where a complete diagnosis cannot be obtained from ultrasound alone. Further diagnostics may be needed such as aspirates or biopsies. Once the ultrasound is complete and images have been obtained and reviewed, my veterinarian will discuss the results with me and any recommendations guided by the findings. *

I understand and agree

Signature of owner/owner’s agent *

Clear Signature

Phone number where you can be reached today *

Other Information

Was the patient fasted?

Yes, he/she did not eat this morning.
No

How has the pet been doing since the last time you spoke to one of our veterinarians? Any changes? *

Pick-up details/plans

Drop off for ultrasound, will pick up later
Owners waiting to take pet home (inform this can take up to an hour)

at approx.

Ultrasound Consent Form

Ultrasound Consent Form

Other Information

We Proudly Serve the Pets of Hershey, PA, and Beyond.

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