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INTERNAL MED : ULTRASOUND CONSENT FORM

Gold Coast Center for Veterinary Care

770 W Jericho Turnpike, Huntington, NY 11743

(631)-923-2530

Date:

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Owner Name:

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Address:

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Client Phone Number:

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Pet's Name :

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Species:

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Breed:

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Sex:

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Age:

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Color:

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Please initial after each statement below:

I give authorization for Gold Coast associates to perform an ultrasound on my pet.

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Signature

The purpose of this ultrasound has been previously explained to my satisfaction.

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Signature

I understand that I assume full financial responsibility for all services rendered.

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Signature

I have read and understand this authorization form in its entirety.

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Client Signature:

Signature