Client Participation Consent

advertisement
Department of Communication
Sciences and Disorders
College of Allied Health Sciences
University of Cincinnati
PO Box 670379
Cincinnati, OH 45267-0379
Animal Audiology Clinic & Bioacoustics Laboratory
Peter M. “Skip’ Scheifele, MDr, Ph.D., LCDR USN (Ret.), Director
David Brown, Ph.D., Assistant Director
Debbie Kemper DVM, Audiology Clinic Veterinarian
3202 Eden Avenue
119 French East Building
Phone (513) 558-8503
Fax
(513) 558-8500
Email: fetchlab@uc.edu
Web
www.uc.edu/csd
Dear Pet Owner:
Your dog has been referred to receive a hearing test. The results of the tests performed will not only tell
whether your dog can hear but how well he can hear and if the dog cannot hear, potentially, what the
nature of the hearing loss is. Your dog will receive a general ear examination perhaps followed by an
Otoacoustic emmissions (DPOAE) test. The DPOAE test tells us whether or not your dog’s inner ear is
functioning. Provided the DPOAE yields a “PASS” then an Auditory Brainstem Response (ABR) test
will be given. Note the ABR is sometimes referred to in the literature as a Brainstem Auditory Evoked
Response (BAER) or Auditory Evoked Potential (AEP) test. Your dog will then be sent home or referred
for further imaging (under a different protocol). The report of auditory health will be provided to you
and your referring veterinarian. Upon completion of the DPOAE, we will then run an Auditory
Brainstem Response (ABR) test. We will be using very tiny subdermal needles placed in three (3)
different locations on the dog. Foam ear inserts will be inserted into the ear canal being tested. This
protocol may take up to 120 minutes after which your dog can go home.
Your dog must be referred by a veterinarian who is not employed by the University of Cincinnati
(UC). You have received a form for your veterinarian to fill out telling us important facts about the
present health of your dog. This is important information that can help us in assessing your dog’s
hearing. If accepted for screening/assessment your referring veterinarian will administer or have
you administer a sedative just prior prior to arrival at UC. Your dog will simply lie on a small
table or for large dogs on the floor or in your arms (as for puppies) and rest during the procedures. If
you wish to have OFFA certifications we have the form here. The test requires the dog to stay
relatively still so consult with your veterinarian regarding the necessity for sedation (a mild oral
sedative). Sedation is not required nor desired for puppies. Both you and your referring
veterinarian will receive a report on the state of your dog’s auditory health and any
recommended follow-up activities necessary. At FETCH~LAB all hearing
screenings/assessments are always analyzed and confirmed by two (2) audiologists, an animal
bioacoustician, and a veterinarian.
You understand that your dog’s participation is voluntary and that you may withdraw your dog from the
test at any time. You also understand that you remain responsible for you dog’s health and behavior and
that UC will not be responsible for injuries to your dog or injuries or property damage caused by your
dog.
DOG OWNER
Signed:__________________________
WITNESS (FETCH~LAB PERSONNEL)
Signed: ______________________
Name: __________________________
Name: ________________________
Date:
Date: _________________________
__________________________
Owner Phone ____________________
An affirmative action/equal opportunity institution
Download