Ultrasound Consent Form

Help us provide safe, accurate diagnostic care for your pet at Victoria Veterinary Clinic.

About Our Ultrasound Services

Our ultrasound services allow our veterinary team to evaluate your pet’s internal organs in a non-invasive, pain-free way. Ultrasound imaging may be used to assess abdominal organs, identify abnormalities, guide diagnostics, or monitor ongoing conditions. In some cases, light sedation may be recommended to help your pet remain comfortable and still during the procedure. If additional findings arise, our team will discuss next steps and treatment options with you. Please complete this form before your pet’s scheduled ultrasound and share any relevant medical history, medications, or current concerns.

Complete the Form

Consent Form for Ultrasound

Date of Ultrasound(Required)

MM slash DD slash YYYY

Patient Name(Required)

Client Name(Required)

First Last

Email(Required)

Is your pet fasted?

Yes

Is your pet on any medications?

Yes

Name of the Medication

If your pet is taking multiple medications, list them all here.

Dose of the Medication

If your pet is taking multiple medications, list the dose for each medication.

Medication Last Given

If your pet is taking multiple medications, list the date each medication was last given.

Any additional signs of illness?

Yes

If yes, please explain:

Abdominal Ultrasonography is a non-invasive technique used to image organs within the abdomen and /or chest. The area to be imaged must be shaved in order to provide adequate imaging. Irritation may occur to the skin as a consequence. Hair regrowth generally takes multiple weeks to occur, but can be more prolonged in certain pets.

Check for Authorization(Required)

Ultrasound / Sedation / Hospitalization $443.50

In the event the ultrasonographer finds any masses/tumours/questionable areas of interest, the veterinarian may recommend sampling of this tissue (e.g. fine-needle aspirate, or biopsy). If your pet requires sampling, please read and initial one of the following statements

Tissue Sampling Authorization

I authorize the attending veterinarian to proceed with any tissue sampling that may be recommended, and take full financial responsibility for the associated additional costs ($264.00 for collection and laboratory analysis) where/if applicable. OR…

I prefer NOT to have any sampling done, and understand that if I change my mind at a later date, the ultrasound will need to be repeated at additional cost. I also understand that a definitive diagnosis MAY not be able to be reached if I decline recommended laboratory testing.

Authorization for treatment and procedures(Required)

I authorize and direct the Veterinarians of the Victoria Veterinary Clinic to perform the services indicated above and/or do any other therapeutic procedures that in their judgment may dictate to be advisable for my pet’s well-being. The risks and nature of the procedures have been explained to me, and no warranty or guarantee has been made as to the result or cure.

Fees must be paid before my pet leaves the clinic.

I can be reached at the following phone number(s):(Required)

Name(Required)

First

Signature(Required)

Download PDF Form

Request an Appointment Today

Victoria Veterinary Clinic offers full-service veterinary care for dogs and cats in Regina, SK, as well as nearby areas like White City, Pilot Butte, Lumsden, Emerald Park, and East Regina. As a Fear Free Certified clinic, we focus on reducing stress while providing expert care in wellness, surgery, diagnostics, dentistry, and cat boarding. Ready to get started? Request an appointment below.

Request Appointment

Have a Question?



Location

Victoria Veterinary Clinic
628 Victoria Ave
Regina, Saskatchewan S4N 0R1



Contact

Phone: (306) 522-8802
Email: vvetclinic@gmail.com



Hours

Monday – Thursday: 7:30 AM – 7:00 PM
Friday: 7:30 AM – 6:00 PM
Saturday: 9:00 AM – 4:00 PM
Sunday: Closed
Statutory Holidays: Closed

Company

This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Email(Required)

Phone

How can we help you?(Required)