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To: Dr. Thomas, Dr. Gaffney, Dr. McPalmer, Dr. Barrett and the staff of Mulnix Animal Clinic,

I am the owner or agent of the above-named animal and have authority to execute this consent. I hereby authorize the performance of the following procedure(s):

Procedure(s)(Required)

Full Abdominal Ultrasound - $436.40

Recheck ultrasound (MUST be within 2 months of initial ultrasound) - $340.00

Focused Ultrasound - $259.50

Echocardiogram - $541.50

Echocardiogram with ECG - $631.50

Sometimes a mild sedative is needed to help the patient relax during the ultrasound. This injection is $75.00 to $107.00.

Sedative Choice(Required)

I authorize the use of a mild sedative if needed

I do NOT authorize the use of a mild sedative

If the above mild sedative is not enough to relax your pet we may need to use additional sedation during the procedure in order to accurately and safely perform the ultrasound. If additional sedation is deemed necessary for your pet, the following procedures would need to be performed:

Additional sedation - $136.80
Anesthetic Monitoring - $73.00
Hospitalization – surgery/sedation - $40.00

Total: $254.80

Additional Sedative Choice(Required)

I agree to the above costs of additional sedation if deemed appropriate

Do NOT proceed with additional sedation

If abnormalities are found during the ultrasound, and an ultrasound guided needle aspirate and cytology, or Internal medicine review of the area is recommended, to aid in further diagnosis, I agree to the following optional procedures and understand that they will be performed at the provided costs:

Optional Procedure(s)

Ultrasound Guided Needle Aspirate and cytology (1 site) - $307.80

Ultrasound Guided Needle Aspirates and cytology (2 sites) - $480.90

Internal Medicine review of Ultrasound - $150.00

I authorize the use of such anesthetics as you deem advisable, as mentioned above, and performance of such therapeutic procedures as you determine to be indicated. I agree to indemnify and hold you harmless from and against any and all liability arising out of the performance of any of the procedures referred to above

I understand full payment is due at the time services are rendered.

I understand that shaving areas of fur (the abdomen and/or chest) is necessary for accurate ultrasound results. Although rare, skin irritation may occur at shaved sites.

We will take every precaution to keep your pet safe while under anesthesia. Occasionally an anesthetic emergency will arise and additional care will need to be administered. Please review the following options and select one option and initial.

In the event an unlikely emergency should occur with your pet in our care I authorize Mulnix Animal Clinic to initiate emergency treatment. If unable to reach you at the given number below please:

Resuscitation Options(Required)

proceed with resuscitation

do no proceed with resuscitation

Resuscitation Limit(Required)

Up to $500 additional

Up to $1000 additional

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Ultrasound Treatment Form

Expert Veterinary Care in Fort Collins, CO