Outpatient Ultrasound Request Form
Please fill out this form to request an appointment with our internal medicine specialist Kimberly Hammer, VMD, DACVIM (SAIM).
This is a request for:
*
Please Select
Abdominal Ultrasound
Thoracic Ultrasound (non-cardiac)
Abdominal Ultrasound + Internal Medicine Consult
Internal Medicine Consult ONLY
Internal Medicine Recheck
Best method of contact for you, the RDVM (Please provide a phone number & e-mail address)
*
Hospital Name:
*
Name of Referring Veterinarian:
*
Patient Name:
*
Clients Name:
*
First Name
Last Name
Best method of contacting the client (Please provide a phone number & e-mail address)
*
Patient Identifier (ID# used for the patient at your practice)
Signalment: (Patient's age, breed, sex)
*
Reason for Ultrasound/Consult
*
Current Medications List
Name of Drug
Route
Dose in mg
Frequency
MED 1
MED 2
MED 3
MED 4
MED 5
MED 6
Pre-Visit Medications and Sedation
Unless medically contraindicated, patients should receive trazodone and/or gabapentin prior to their visit to facilitate patient relaxation and improved quality of study. Please dispense these oral medications from your practice. If we have not seen the patient at our hospital within the last year, we will not be able to dispense pre-visit medications prior to the scheduled ultrasound.
Permission for Sedation?
*
Please Select
Yes and a protocol is provided below
Medically Contraindicated
Not applicable
Sedation Protocol
Name of Drug
Route
Dose in mg
MED 1
MED 2
MED 3
MED 4
MED 5
MED 6
Permission for Aspirates of Organs/Effusions?
*
Please Select
Yes
No
Not applicable
Please upload any appropriate records for client or e-mail records@abseconvet.com:
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