Echo & Ultrasound Referral Form
Date
-
Month
-
Day
Year
Date
Referring Clinic
*
Client Name
*
First Name
Last Name
Client Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Primary Contact Number
*
Please enter a valid phone number.
Client Secondary Contact Number
Please enter a valid phone number.
Client Email
*
example@example.com
Pet Name
*
Species
Please Select
Canine
Feline
Rabbit
Pocket Pet
Bird
Breed
Patient's Birthday/Age
Sex
Please Select
Male
Female
Neutered Male
Spayed Female
Pet History
History(for cardiac ultrasound patients please note history of cough, exercise intolerance, changes in appetite and energy level):
Abnormal physical exam findings:
Recent diagnostic tests:
List your differentials:
If on cardiac medications, any concerns regarding administration? Please write N/A if not currently on any cardiac medications.
If being recorded, what is the patient resting respiratory rate? If not being recorded, please write N/A.
Current medications: (include name, dose and when last given) Enter N/A if patient is not on any medications
Any other medical concerns:
Please select a Radiologist to review the images (for abdominal ultrasound)
Idexx
Antech
Sonopath
I understand that all canine patients must come with Gabapentin (30-40 mg/kg) and Trazodone (5-10mg/kg up to 300mg) given 2 hours prior to procedure.
Yes
I understand that all Feline patients must come with Gabapentin 100mg given 2 hours prior to procedure.
Yes
Submit
Should be Empty: