Outpatient Ultrasound Referral Form

Outpatient Ultrasound Referral Form

Please fill in the information below to submit a request.
Referring Clinic / Hospital*
Referring Veterinarian*

First NameLast Name
E-mail*
Client Name*

First NameLast Name
Contact Number*
Patient Name*
Species*
Breed*
Age/DOB*
Weight*
Gender
Sterilised
Study (Check where applicable)*

UltrasoundEchocardiogram
Ultrasound

AbdomenNeckMusculoskeletalOcularThoracicOther
Presenting Problem / Tentative diagnosis
Clinical question / Region of interest
Case history / Summary of physical examination findings
Current treatment(s) (including medications and dosages)
Any concerns regarding sedation? (ultrasound only)*

NoOther
Previous Imaging (Check where applicable)*

Radiograph(s)Previous ultrasound images/reportOther
Please upload any relevant imaging

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Has the patient's history been sent to hx@lvs.com.sg?*

YesNo
Please upload patient history if it has not been sent via email

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Confirm Submission
The ultrasound report will be emailed to the referring veterinarian 24 to 48 hours after completion of study.
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Date*

DayMonthYear
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