X-Ray Consent Form

Owner’s/Agent’s Name *

First

Last

Email *

Phone

Pet's Name *

I, the undersigned owner or agent of the owner of the pet identified above, certify that I am eighteen years of age or over and authorize the veterinarian technician(s) at this practice to perform the above procedure(s) in my home. *

I have read, understand, and authorize.

In order for an x-ray examination to be performed in the home, I understand that the use of a 120-volt outlet is needed and that The Welcome Waggin’s generator does not support extension cords. I also understand that The Welcome Waggin’ requires a room that is at least 6 feet by 6 feet wide to set up its equipment. *

I will supply our X-Ray team with the appropriate space to take x-rays.

All individuals whose presence is required during an x-ray examination shall be protected from scatter radiation by protective aprons or gowns of not less than 0.25-millimeter lead equivalent or whole-body protective barriers. I understand that scatter radiation will extend out to 6 feet during this process. Each member of The Welcome Waggin’s technician team will be dressed accordingly to take x-rays. I understand that The Welcome Waggin’ will not have any additional protection clothing or equipment for myself or any other person that is not an employee or contractor of The Welcome Waggin’. I understand that this means that once the x-ray process is to begin, I, and any other persons that are not employees or contractors of The Welcome Waggin’ must leave the room being used. I understand that the technician will call the owner once the x-rays have been taken and that no individual, other than the operator, shall be in the x-ray room or area while exposures are being made unless such individual's assistance is required. *

I acknowledge and I understand that there are scatter radiation risks associated with radiographs and that I am encouraged to discuss any concerns I have about those risks with the attending veterinarian technician(s) before the procedure(s) is/are initiated.
I acknowledge that I cannot be directly present during the x-ray procedure and will leave the designated room once the technician team is all set up and ready to go. I understand that any procedure done to a pet can carrier risks, but that The Welcome Waggin’ utilizes low stress handling techniques, and its doctors may be prescribing pre-visit pharmaceuticals to help decrease anxiety and pain associated with the procedure.
I understand that there are risks with any procedure and I have discussed my concerns about those risks with the attending veterinarian before the procedure is initiated.

To the best of my knowledge, my pet has not bitten, scratched, or otherwise potentially exposed any person or other animal to rabies in the past ten (10) days. I understand that if the animal described above has bitten or otherwise potentially exposed any person within the time specified above, a rabies test must be performed. *

I have read, understand, and authorize.

I understand that all X-Rays are to be ordered by the veterinarian attending to my pet’s case, and that unless otherwise directed, all radiographs will be sent to a board-certified Radiologist for interpretation. I understand that The Welcome Waggin’s technician team cannot discuss the results of the x-ray procedure findings with me, and that the interpretation of the results can take up to 7 days following the visit. *

I acknowledge that I will not get answers or interpretation of results immediately and will not press the veterinary technicians for results they are unauthorized to give.

By signing the Consent Form, I hereby fully release, discharge and covenant not to sue The Welcome Waggin’, its officers, members, successors, agents and assigns from any and all claims, demands, obligations, liabilities, injuries, illness, personal injury actions or causes of actions for personal injury, including death, arising out of or related to my failure to adequately adhere to any and all safety and health precautions set forth in this Consent Form. Acknowledging the above, I consent to and authorize the performance of x-ray imaging to my pet. My signature on this form indicates that any questions I have regarding the following procedure(s) have been answered to my satisfaction. *

Acknowledging the above, I consent to and authorize the performance of x-ray imaging to my pet. My signature on this form indicates that any questions I have regarding the following procedure(s) have been answered to my satisfaction.

Owner/Agent's Signature *

Clear Signature

Date *

Are you the owner or agent? *

Owner
Agent

Owner/Agent Printed Name *

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