Page 3334 - Cote clinical veterinary advisor dogs and cats 4th

Consent to Perform Radiography

VetBooks.ir Patient name:_________________________________
Pet owner’s name:_____________________________ Med rec #____________
Best contact during/after procedure (e.g., cell phone number):____________________

INTRODUCTION ALTERNATIVES TO THE PROCEDURE
We want to make sure that you understand the planned medical Depending upon the area of the body we are interested in learning
procedure to be performed on your pet. You should know why the more about, other imaging modalities such as ultrasound (sonog-
procedure has been suggested, what the potential benefits are for raphy), magnetic resonance imaging (MRI), fluoroscopy, positron
your pet, and the most common/important risks of the procedure. emission tomography (PET scan), or a computed tomography (CT/
Alternatives to this procedure, when applicable, will be discussed CAT) scan can be performed. The pros and cons of these proce-
with you. It is also important that you recognize that medicine is dures can be more specifically discussed if you are uncomfortable
not an exact science, and that the outcome cannot be guaranteed. with radiographic imaging for any reason. Without the additional
We encourage you to ask us as many questions as required for information provided by images, we would need to develop a
you to make a well-informed decision. treatment plan without a confirmed diagnosis, which might lead
to a suboptimal outcome.
BENEFITS/OPTIMAL OUTCOME OF THE PROCEDURE
Radiographs, or x-ray images as they are known more commonly, AUTHORIZATION
can help us identify tissue and bone abnormalities. Performing By signing this form below, you agree that:
radiographs is not a treatment for disease; by taking radiographs, • You understand how/why the procedure is likely to help your
we aim to find a diagnosis that we can treat. pet
• You understand what will be done to your pet during the
EXPLANATION OF THE PROCEDURE procedure
Your pet will lie on a special table for a few minutes while radiographs • You understand the known risks that accompany the procedure,
are taken of the area of interest. Areas of interest can include the and also understand that unforeseen complications may occur
chest, the abdomen, the neck, the head, or parts of the limbs. • You understand that the procedure may not produce the results
Multiple views are obtained from different angles. Depending upon we hope to achieve
where and why the radiographs are being taken, or if your pet is • You understand the alternatives to this procedure for your pet
painful or anxious, a sedative medication may be administered to help • You agree that you have been given time to ask questions regard-
him or her lie still enough for us to obtain diagnostic quality images. ing the procedure, that these have been answered satisfactorily,
Additional procedures planned for your pet at the same time and that you are free to decline the procedure.
as the radiographs:

____________________________________________________________ ____________________________________ ______________
USE OF SEDATIVES OR ANESTHESIA Signature of pet owner/owner’s agent Date
Sometimes in order to obtain diagnostic quality radiographs and to
minimize pain and stress for your pet, sedation may be necessary. ____________________________________ ______________
Sedation will involve the administration of medications that cause
your pet to become drowsy and relaxed, but to remain conscious. Witness to consent (signature) Date
You pet will remain in control of vital functions such as breathing.
In general, there are fewer risks associated with sedation than ____________________________________
with general anesthesia, but adverse events do occur very rarely,
including death. Many medications used to induce sedation can be Witness to consent (printed name)
“reversed” by giving other medications to counter the sedative effect,
allowing your pet to “wake up” more quickly after the procedure
has been completed.
FORESEEABLE RISKS TO THE PROCEDURE
Because x-ray exposure is minimal, no major complications are
expected as a possible outcome to this procedure. There is, however,
a risk that despite obtaining good radiograph images, we may not
identify a specific cause for your pet’s illness.

Other anticipated risks specific to your pet:___________________

_________________________________________________________
Practice Stamp or Name & Address
Also available in Spanish.

From Cohn and Côté: Clinical Veterinary Advisor, 4th edition. Copyright © 2020 by Elsevier Inc. All rights reserved.