Ultrasound Referral Form

Outpatient/Mobile Ultrasound Referral Form

Please fill out this form with basic information for your client and their pet(s)
For outpatient abdominal ultrasound services, on-premises clients will pay WCAH directly. Mobile ultrasound services will be billed to your practice.

Ultrasound includes 50-60 high quality images w/measurements

Radiologist Ultrasound Report will be emailed within 2 - 4 business days.

If patients on premise require sedation, consultation with a staff veterinarian and additional charges may apply.
Pet's Name*
Patient ID number
Weight (specify lb/kg)*
Breed*
Species/Gender*
Pet's Age/DOB*

MonthDayYear
Date
Client's Name*

First NameLast Name
What service is needed?*

Abdominal Ultrasound
Referring DVM Name*
Referring DVM Email*
Referring DVM Phone*
Referring Office Name
Priority & Turn Around Time*

Routine (within 4 days)Priority (within 13 hours) +$65 additional
Was the patient sedated for this exam?*

YesNo
* Patient History: Please summarize the patient's history and clinical signs that prompted this ultrasound exam.*

Include duration of clinical signs, severity of signs, any known triggers, etc0/500
Physical Exam: Please summarize the physical exam findings for this patient*

If not performed, please specify. Include Temp/Pulse/Respiration, MMs and demeanor0/500
Diagnostics completed:

Other than this study, please summarize results of any completed diagnostics. Leave blank if N/A.0/500
Do you have a treatment plan for the current clinical signs?*

YesNoTreatment pending imaging interpretation
If treatment plan is available please describe

If no plan available, type "N/A"0/250
What clinical question/concern would you like answered with this study?

This information will help the specialist address your specific concerns for this patient.0/250
Is there any additional medically pertinent information?*

YesNo
If yes, please provide the medically pertinent information

0/250
Should be Empty:

Outpatient/Mobile Ultrasound Referral Form