Outpatient - Veterinarian Referral

SSVI Outpatient - Veterinarian Referral

This referral form is exclusively for those patients being referred directly by a veterinarian overseeing their care. IF YOU ARE AN OWNER, please fill out the owner referral form.
Patient Name*
Pet Name Only
Species*
Sex*
Breed*
Age*
Owner Name*
First Last
Owner Phone Number*
Owner Email Address*
Owner Address*
Street, City, Zip
Referring Veterinary Clinic*
Referring Veterinarian*
Referring Veterinary Phone Number*
Referring Veterinary Email Address*
Phone contact for referring veterinarian in case of urgent need *
(if different from above)
Is the patient exhibiting any of the following clinical signs? Please explain below. The patient needs to be stable for an outpatient ultrasound. If the patient is not stable, ER referral is recommended.*

DyspneaExtreme LethargyCollapseObtunded/comatose103.5 or greater body temperaturePulse DeficitsClinical arrhythmiaNone of the above
If any of the above checked, please explain severity and agree that your patient is stable for an outpatient ultrasound.
Will this patient need sedation? Please note, if the patient needs injectable sedation, the image study will be cancelled, we are unable to provide injectable sedation currently. Orals (such as gabapentin, trazodone) are highly recommended day off and night before for all patients. Please prescribe accordingly.*

Yes, we will provide oral medicationsNo this patient has not needed medication
Ultrasound type requested*
If FNA only or other, please explain
Urgency of ultrasound
Indication for study - please be specific in terms of patient clinical signs, clinical history and what questions like answered by the sonographer. Failure to provide adequate history may result in cancelation of appointment and will require re-submission of the request form.*
Does your patient have a recent (within last month) bloodwork (CBC & Chemistry)? If not we strongly recommend CBC prior to appointment if FNA is indicated. Lack of CBC may require bloodwork prior to and additional visit for FNA*

YesNo
If your patient does not have recent bloodwork and requires an FNA, the patient will need to return to have the procedure done at a later date. The client can elect to have the CBC/Chemistry run through their primary care or SSVI.
If the patient has send out diagnostics, how would you like the owner to get results?*

Please have SSVI nurse call the owner with results and instruct them to follow up with you as needed. Results will be sent to you by email as well.Please email me the results and I will review them with the owner.
Routine first-visit ultrasounds start at $725. Further diagnostics will be performed for an additional fee. Common fees available on website. Payment is due at the time of service.*

Please check box to agree
SSVI veterinary nurse or veterinarian will review preliminary ultrasound findings with the client. We will instruct them to follow up with you for further care. We will not discuss non-pertinent medical history or non-imaging follow up with the client.*

Please check box to agree
We will send the final report to you with 48 hours of the ultrasound (same day for STAT or urgent cases). If clinical judgement deems urgent, a member of the SSVI team will attempt to contact you at the number provided above.
Please upload any pertinent files. Please only include records relating to the indication for the study.

Cancelof
Should be Empty:

SSVI Outpatient - Veterinarian Referral