Ultrasound & Echo Referral Form
Thank You for the Referral!
Referring Veterinarian’s Information
Name
Vet Clinic
Email
example@example.com
Client's Information
Name
First Name
Last Name
Cell Phone Number
Please enter a valid phone number.
Email
example@example.com
Patient's Information
Name
Species
Please Select
Canine
Feline
Breed
Age / DOB
Sex
Please Select
Male
Female
Male Neutered
Female Spayed
Type of Referral
Please Select
Ultrasound
Echocardiogram
Please list primary problem or concern and outline any pertinent medical history:
Previous Diagnostic Tests Performed/Results/Dates:
Previous Relevant Surgical and/or other Procedures Performed with Dates:
If any abnormalities (masses, nodules, free fluid) are found during the scan would you like aspirates performed and samples sent for cytology? :
***Please be sure that clients are made aware of the following***
All of our ultrasound and echo studies are performed by a fully trained CVT.
If additional diagnostics such as fine-needle aspiration are necessary and able to be performed, we will provide an appropriate estimate to the client and will only proceed with their consent.
The patient will only be seen for the ultrasound no information will be given about any findings. All reports will be sent to you to review with your client.
Client is aware that you, their primary veterinarian, will be responsible for reviewing the ultrasound findings and discussing the next steps.
The patient needs to have been fasted for 12 hours prior to the ultrasound.
Patient may need to be sedated for safety and/or diagnostic accuracy reasons.
Patient’s abdomen will be shaved for ultrasound.
Submit
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