Ultrasound Referral Form
When referring your patient to our hospital, please complete this form and upload all pertinent medical records.
Please select the type of referral:
*
Please Select
Ultrasound
Referring Veterinarian Information
Hospital Name
*
Clinic/Hospital Phone Number
*
Please enter a valid phone number.
Clinic/Hospital Fax Number
Please enter a valid fax number.
Clinic/Hospital Email
*
example@example.com
Referring Veterinarian
*
First Name
Last Name
Client Information
Name
*
First Name
Last Name
Name of secondary contact and/or spouse:
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Patient Information
Name
*
Birth Date
*
-
Month
-
Day
Year
Approximate
Age
*
In months/years, or birthdate
Species
*
Breed
*
Colour / Markings
*
Sex
*
Male
Female
Spayed/Neutered
*
Yes
No
Weight:
*
In kg
Vaccine Status:
*
In lbs or kg
Underlying Condition:
*
In lbs or kg
Required documentation / information
Ultrasound service urgency
*
Standard (3-5 days)
Stat (2-6 hours) *Time is dependent on outside radiologist. Please call our office if you choose this option*
Ultrasound service requested
*
Full Abdominal Ultrasound
Single Organ Ultrasound
Musculoskeletal Ultrasound
Fine Needle Aspirate
Biopsy
Please specify (musculoskeletal ultrasound):
*
Front
Back
Bilateral
Left
Right
Please specify (fine needle aspirate):
*
Liver
Spleen
Other
Please specify (biopsy):
*
Please specify:
*
Tentative Diagnosis:
*
Present Complaint:
*
Upload Required Documentation:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
*
I understand that
images and videos are interpreted via telemedicine by a board-certified radiologist. We do not discuss the results with your client.
Once a report is received we forward it to the referring Veterinarian for evaluation. Additional information may be required depending on the services selected.
Additional Information / Comments:
Submit
Should be Empty: