Ultrasound Referral
Please fill this form out entirely and upload the required documents at the end of this form to refer a patient for ultrasound. Let your client know we will follow up with them once we've reviewed all of this information.
Name of Clinic Referring the Patient
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Phone Number of Referring Clinic
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Please enter a valid phone number.
Email of Referring Clinic - Records will be submitted back to you via this email
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Differential Diagnosis/Reason for Referral
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Name of Person Filling Out the Form
*
Patient and Client Information
Name of Client
*
First Name
Last Name
Phone Number of Client
*
Please enter a valid phone number.
Type of phone number
*
Mobile
Landline
Address of Client
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email of Client
*
example@example.com
Name of Patient
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Species
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Canine
Feline
Breed
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Color
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Weight
*
Sex of Patient
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Female Spayed
Male Neutered
Female
Male
Birthdate of Patient
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List all Current Medications and Supplements the Pet is Taking
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Does this pet have any major health issues (diabetes, kidney disease, etc)?
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Expectation for this case:
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Ultrasound and interpretation
Ultrasound only (referring DVM will interpret)
Other
Is a biopsy needed?
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Yes
No
Other
If a biopsy is warranted, what would you like us to do with the sample?
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Send it out for histopathology through IMAH, but provide the results to me so I can follow up with the client
Give it to the client in a jar of formalin to be returned to my clinic to send out for histopathology
Not applicable
Pertinent History:
*
Required Uploads
Please use this area to upload the required documents for us to move forward with the referral. Please note, we will not be able to move forward with this referral until all files are uploaded and sent.
Please upload full medical records, including detailed doctor's notes, here:
*
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Please upload any bloodwork here:
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Please submit any imaging (radiographs or other) here:
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Submit
Should be Empty: