Healthcare Ear Mites Form

HEALTHCARE EAR MITES FORM

Clinic / Facility Information

Clinic Name:

Attending Clinician:

Patient (Animal) Information

Patient Name:   Species:

Breed:   Color:

Date of Birth / Estimated Age:   Sex: Male Female Neutered/Spayed

Microchip / ID #:

Owner / Responsible Party

Insurance / Payment Responsibility

Insurance Provider:   Policy #:

Subscriber Name:   Group #:

If no insurance, owner accepts full financial responsibility for services rendered and medications dispensed.

Medical History

Date of Last Ear Treatment:

Clinical Assessment and Recommended Treatment

Clinical findings and planned procedures will be performed by the attending clinician. Typical diagnostic and treatment options for suspected ear mite infestation include the items below. Please initial consent for each selected item:

Ear examination with otoscope

Ear cytology (microscopic exam of ear discharge)

Medical ear cleaning (removal of debris and wax)

Topical acaricide / medication (ear drops)   Medication name:

Oral medication if indicated   Medication name/dosage:

Sedation or restraint if required for thorough cleaning or diagnostic sampling

Additional diagnostics or treatments as clinically indicated (culture, cytology follow-up)

Risks, Benefits and Alternatives

I understand that ear mite treatment is intended to remove mites and associated debris and to resolve clinical signs. Benefits include reduction of irritation, infection control when present, and improvement in comfort. Potential risks include local irritation, transient discomfort, allergic reaction to medications, incomplete resolution if secondary infection or concurrent disease exists, and, rarely, vestibular signs with topical treatments. Ear cleaning may reveal perforation of the tympanic membrane or require further treatment. There is a low risk of zoonotic transfer to humans; appropriate hygiene is recommended.

Alternatives include deferred treatment, topical-only therapy, or referral for advanced diagnostics. Declining recommended therapy may result in ongoing clinical signs, spread to other animals, and potential worsening of underlying disease.

Authorization and Consent

By signing below I certify that I am the owner or authorized agent of the owner of the patient identified above. I authorize the attending clinician to perform the selected procedures and to administer medications and sedation if necessary. I authorize performance of additional diagnostic or therapeutic procedures discovered to be necessary during the course of treatment up to the pre-authorized amount of: $ .

I accept financial responsibility for all charges incurred and understand payment is due according to clinic policy. I release the clinic and its personnel from liability for unforeseen complications arising from treatment except in cases of gross negligence.

This authorization remains in effect until: unless revoked in writing prior to the procedure. Revocation does not affect actions already taken in reliance on this authorization.

Release of Records / Referral

I authorize release of relevant medical records pertaining to this patient's ear condition to other veterinary providers for referral or continuity of care as necessary. I understand a copy of diagnostic results may be retained in the clinic medical record.

Acknowledgment

I have read and understand the information above. I have had the opportunity to ask questions and these questions were answered to my satisfaction. I acknowledge that there are no guarantees regarding outcome and that follow-up care may be required.

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