Mobile Echo Patient Form

For Dr. Maisenbacher Mobile Echocardiogram Patients

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Pet Name *

Owner Name(s) *

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Name *

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Best Phone Number *

Alternate Phone Number *

Email *

Virginia Veterinary Hours Disclosure Form
Mt. Pleasant Veterinary Clinic has business and medical staffing hours as follows:
Monday-Thursday: 8A-6P
Friday: 8A-5P
Saturday: 8A-1P
CLOSED Sundays and holidays

This notice is to inform you that Mt. Pleasant Veterinary Clinic does not have on-duty medical staff care during the following hours:
Overnight: from closing time until 8am the following workday
Monday 6P-Tuesday 8A
Tuesday 6P-Wednesday 8A
Wednesday 6P-Thursday 8A
Thursday 6P-Friday 8A
Friday 5P-Saturday 8A
Weekend: from closing time at 1pm on Saturday until 8am Monday
Holidays: from closing time before the holiday until 8am the next workday.

I certify that I am aware of the staffing hours. Name: *

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Anesthesia / Surgical Consent.

Procedure(s) to be performed: *

I, the undersigned owner or agent of the pet identified above, authorize the staff of Mt. Pleasant Veterinary Clinic to perform the above procedure(s).

I understand that some risks always exist with anesthesia and/ or surgery and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedure(s) is/are initiated.

I understand that the attending veterinarian will make every effort to contact me regarding treatment in the case of unforeseen emergencies. If unable to contact me, the staff has my permission to proceed with life sustaining procedures. Name or "Don't Agree" *

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While I accept that all procedures will be performed to the best of the abilities of the staff at this hospital, I understand that no guarantee or warranty has been made regarding the results that may be achieved.

I also assume full responsibility for any additional expenses incurred after the surgical procedure is performed, such as follow up radiographs, re-check physical exams and additional surgery due to post-op complications. These are more likely to occur when there is a failure to comply with the aftercare instructions.

A complete physical exam will be performed on your pet prior to the surgical procedure if it has been longer than 30 days since the last exam. However, this may not identify all systemic or metabolic problems. For this reason, your pet will have a pre-anesthetic blood panel to evaluate major organ functions prior to anesthesia.

I have read and fully understand the terms and conditions set forth for payment, warranties, and exams. Name: *

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Your Mobile Cardiac Consultation and Echocardiogram Consent

Your veterinarian has recommended that your pet have a cardiac consultation and echocardiogram performed by Dr. Herbert Maisenbacher, who is a board certified veterinary cardiologist. An echocardiogram is an ultrasound of the heart. It is a noninvasive and painless procedure, which allows the beating heart to be imaged in order to assess the structure and function of your pet's heart. In addition to this, Dr. Maisenbacher will complete a cardiovascular exam on your pet and review all pertinent medical records, including previous diagnostic test results. Based on the results of the consultation and echocardiogram, Dr. Maisenbacher will work with your veterinarian to determine the best treatment and follow-up plan.

An echocardiogram can be an extremely helpful test, but as with all diagnostic tests, there are limitations including, but not limited to, those listed below:

An echocardiogram uses ultrasound to image the heart and its surrounding structures, but several factors (such as obesity, chest shape, excessive movement/panting, lung disease, chest malformations) can make it difficult or impossible to assess all of the cardiovascular structures.
An echocardiogram does not assess the heart rhythm or lungs. If abnormalities are suspect in these, an electrocardiogram (ECG) and/or chest X-rays may be necessary.
An echocardiogram can assess the majority of the structure and function of the heart, but for many reasons, other tests (such as bloodwork, X-rays, ECG, Holter monitor, CT/MRI, tissue/fluid analysis) may be necessary to obtain a definitive diagnosis or determine the optimal treatment plan.

I, the undersigned, have read the information above and by signing below understand and consent to the following: Dr. Maisenbacher will perform the consultation, including the cardiovacular exam, review of medical records, and echocardiogram. The findings and recommendations for treatment and follow-up will be discussed with me by my veterinarian and/or clinic staff. My pet's fur may be clipped for the echogardiogram and collection of fluid or tissue. My pet may need to be sedated in order to allow for a safe and thorough evaluation. Collection of fluid or tissue may be performed during the evaluation for testing and/or treatment purposes. A cancellation fee may be charged for same day cancellations. *

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