Procedure Consent Form PDF Procedure Consent Form As the owner of the animal listed below, I hereby give my consent to Bush Advanced Veterinary Imaging, the attending veterinarian, and the staff of Bush Advanced Veterinary Imaging to administer general anesthesia and perform an MRI (magnetic resonance imaging) and/or CT (computed tomography) and/or a CSF (cerebrospinal fluid) test on the animal listed below. The nature and risks of the procedure have been explained to me and all of my concerns have been addressed. I understand that general anesthesia is required for these procedures and I also understand that a contrast agent may be used in the animal listed below during the course of the MRI or CT. I understand that risks and potential complications do exist with anesthesia, magnetic resonance imaging, computed tomography, the use of contrast agents, and with a CSF tap. These risks and potential complications include, but are not limited to: cutaneous burns, aspiration pneumonia, and/or an abnormal reaction to anesthetic or contrast agents causing anaphylaxis (potentially fatal allergic type reactions), organ failure (heart, liver, kidney), cardiac or respiratory arrest, paralysis, and death. I further realize that complications may arise as a result of my animal’s condition. All of these factors may lead to a decline in medical status and a decision may have to be made regarding my animal’s resuscitation status. If a CSF tap is requested and deemed necessary it will be performed by a licensed veterinarian or Board Certified Veterinary Neurologist through Bush Veterinary Neurology Service.Resuscitation Agreement(Required) I authorize the attending veterinarian and the staff of Bush Advanced Veterinary Imaging to administer all necessary treatments, including CPR (cardiopulmonary resuscitation) if needed. I also understand that the severity of the complications may warrant transfer to our on-site emergency department for more intensive care and I authorize the attending veterinarian to refer the animal listed below to our emergency department. Cost for CPR alone could add $300-$500 to the fees I have already been provided. Additional charges that are incurred for further treatment would be discussed with you by our on-site emergency department. I do not want the animal listed below to be resuscitated in the event of cardiac or respiratory arrest. No life saving measures should be taken. Read Confirmation(Required)I acknowledge that no guarantees have been made except reasonable precautions against injury, escape, or illness with the understanding that I will remain fully responsible for the cost of all services provided by Bush Advanced Veterinary Imaging and its authorized agents. I have read and understand this authorization and consent LocationLeesburgRockvilleSpringfieldClient Name(Required) Prefix Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. First Name Last Name Name of Animal(Required) Date(Required) MM slash DD slash YYYY Emergency Number(Required)
