Mobile Ultrasound Patient Form

For Dr. Kremer Mobile Ultrasound 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: 8Am-6Pm
Friday: 8Am-5Pm
Saturday: 8Am-1Pm
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 6Pm-Tuesday 8Am
Tuesday 6Pm-Wednesday 8Am
Wednesday 6Pm-Thursday 8Am
Thursday 6Pm-Friday 8Am
Friday 5Pm-Saturday 8Am
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 Pet's Ultrasound and Specialist Evaluation

Your vet has recommended that your pet have a diagnostic ultrasound and evaluation performed by Dr. Keith Kremer, who is a board-certified veterinary internist. Ultrasound is a noninvasive, painless procedure that enables one to literally look inside the body and into the organs to better evaluate for disease. Your pet will also be examined and his/her medical record reviewed by Dr. Kremer, who has additional training and expertise in diagnosing and treating pets with complex or serious problems involving their internal organ systems.

While ultrasound can be an extremely helpful test, like all tests it is not perfect and there are limitations to its benefits. Listed below are some key points:

Ultrasound assesses structure of the internal tissues, but does not test actual organ function, which is usually better assessed with other tests (such as labwork and clinical evaluation).
Ultrasound may not be diagnostic for many reasons, and other tests or procedures may ultimately be needed for definitive diagnosis, such as Xrays, MRI, CT (cat scan), biopsies, etc.
Ultrasound cannot evaluate through air or gas pockets, such as intestinal gas or inflated lungs, or very dense structures such as bone.
Ultrasound is very helpful in evaluating for cancer, but cannot reliably differentiate benign masses from cancerous tumors - this requires a tissue sample to evaluate the actual cells.
Needle samples are often performed with ultrasound guidance. A fine needle aspirate collects a very small tissue sample through a small needle. These samples are usually submitted to a pathologist and are most helpful in evaluating for cancer, inflammation, or infection.
Your pet should be fasted for 12 hours before the procedure unless it has blood sugar issues.

Consent for Ultrasound Evaluation

I have read the information above, and by typing my name in the space below, I give consent to the following procedures, and understand that: Dr Kremer will perform the evaluation, including physical exam of my pet, review of his/her medical records, and ultrasound exam. Ultrasound findings and any recommendations for further care of my pet will be discussed with me by my vet and/or the clinic staff. My pet's fur will be clipped for the ultrasound (usually the underbelly). My pet may need to be sedated for the procedure to enable a thorough evaluation. Needle collection of tissue or fluid may be performed during the procedure for testing and/or treatment purposes. A cancellation fee may be charged for same day cancellations. *

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