Ultrasound Consultation Form

Ultrasound Consultation Form
Hospital Name:
Hospital Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Hospital Phone Number:
Please enter a valid phone number.
Hospital Email Address:
example@example.com
Primary DVM:
Patient Name:
Species:
Breed:
Weight:
Age:
Reason for ultrasound:
Fine need aspirates requested?

YesNoUnsure
Biopsies requested?

YesNoUnsure
Will patient be sedated? This is highly recommended to facilitate comfort and timing.

YesNo
If patient will not be sedated, please explain why.
Upload relevant medical records and diagnostics below:

Cancelof
Services Requested

The undersigned veterinary hospital/clinic authorizes Houndsound Mobile Veterinary Ultrasoundto perform:
- Soft Tissue Abdominal Ultrasound
- Fine Needle Aspirate (FNA) (if clinically indicated)
- Ultrasound-Guided Tissue Biopsy (if clinically indicated)
Imaging & Interpretation Process
- All ultrasound images will be sent to a board-certified veterinary radiologist for interpretation
- The completed radiology report will be emailed directly to the hospital typically within 24-48 hours of the procedure
- The original ultrasound images will remain available in digital format for clinic reference
Additional Testing & Requirements
- Pre-procedure bloodwork (CBC/chemistry/coagulation) required for biopsy/FNA cases
- Sedation/anesthesia strongly recommended (clinic responsibility)
- Clinic to provide relevant medical history prior to procedure
Financial Terms
1. 50% non-refundable deposit required to schedule
2. Balance due within 14 days of invoice date
3. Late payments subject to 1.5% monthly service charge
4. Emergency after-hours services may incur additional fees
Hospital Authorization
By signing below, the clinic:
1. Approves all selected services
2. Accepts financial responsibility
3. Confirms owner consent is obtained
4. Authorizes radiologist consultation
Should be Empty: