Pre-ultrasound Form

Sex of Pet *

Male

Male neutered

Female

Female Spayed

Age of Pet

Years

Months

Weeks

Owner Information *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Has your pet been vaccinated for rabies in the past 12 months? *

Yes

No

Has your pet been to AVAH or OAESH previously?

VCA Alta Vista Animal Hospital

Ottawa Animal Emergency & Specialty Hospital

Neither

Have you picked up pre-procedure sedation (ie. gabapentin and/or trazodone) from your rDVM? *

Yes

No

Will be picking up this week

I understand that I will be charged a cancellation fee by my general practice veterinary hospital if I do not cancel the ultrasound appointment with VetSonix within 1 day of the appointment *

1 day prior - 50% service fee Same day/missed appointment - 100% service fee

Yes

VetSonix provides education and training sessions to Veterinarians and Veterinary Technicians through courses and seminars *

VetSonix strives to provide high quality training for veterinary professionals; Use of diagnostic images, such as ultrasound and xray, in seminar and course material helps provide more effective teaching and helps to further the understanding of disease conditions in relation to the ultrasound image. Please note: The confidentiality of our clients is important, and we will never share any personal or private information. (Please choose only 1 option)

I consent to ultrasound and radiograph images and information about my pet being used for educational purposes

I do NOT consent to ultrasound and radiograph images and information about my pet being used for educational purposes