Outpatient Ultrasound Request RDVM Form
Bluepearl Radiology Department- Patricia DeBow, DVM, DAVCR
Referring Hospital Information
*Please note that all outpatient ultrasound requests will be reviewed by our radiology team prior to scheduling appointment- If your request is denied we will call for follow up*
Clinic Name:
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Referring DVM:
*
Email Address:
*
Phone Number
*
Client Information
Client Name:
*
Client Phone Number:
*
Additional Client Phone Number:
*
Client Email Address:
*
Client Address:
*
Patient Information
Patient Name:
*
Breed:
*
Sex
*
Male Intact
Female Intact
Male Neutered
Female Spayed
Species
*
Canine
Feline
Age (years)
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Weight: KG
*
Sedation: The primary drugs we use to sedate outpatients are Dexdomitor and Butorphanol. When there is a patient with known pre-existing heart disease, no dexdomitor is used. Instead, a higher dose of butorphanol is used for sedation. Does this plan work? If not, patient may not be a good candidate for outpatient ultrasound.
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Yes
No
If selected no, please state why
Does the patient have any history of heart conditions?
*
Ultrasound Type/Region:
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Brief with reason for study/primary concerns:
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Date of Patient's Last Physical Exam
*
Doctor Email Address to Receive Report:
*
example@example.com
Please keep in mind that Dr.DeBow will not be reviewing report results with the client directly. It will primarily be the responsibility of the RDVM to communicate these results
Acknowledgment confirmation
*
This pet will be dropped off for their ultrasound and receive sedation for their diagnostic imaging.
Please sign below, acknowledging and understanding you will be responsible for communicating ultrasound results to the client.
*
Continue
Continue
Should be Empty: