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.
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.
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
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?
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.
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.

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SSVI Outpatient - Veterinarian Referral