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)
Ultrasound

Other
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)

Other
Previous Imaging (Check where applicable)

Other
Please upload any relevant imaging

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

DayMonthYear
Should be Empty:

Confirm Submission