Ultrasound Referral Form

Please use the ultrasound referral form below.

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Ultrasound Referral Form

Ultrasound referral is to be completed and sent to us by a referring veterinarian.

Owner’s Information

Name *

First

Last

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Referring Veterinarian’s Information

Clinic *

Referring Vet *

Phone *

E-mail

Fax

Pet’s Information

Name *

Species *

Breed *

Age *

Sex *

Weight (kg)

Temperament

Please fill in history as requested below. Please ensure your client is aware of costs prior to their visit

Case History *

Presenting Complaint *

Organs of Interest *

Physical Exam Summary

Completed Diagnostic Summary

Current Medications/Treatments

Differential Diagnosis

Private Comments (This will not appear on the Ultrasound report)

Once all information is collected, we will contact the owner to set up an appointment.

Information for referring Veterinarians:

Canine: Please give your patient a sedating dose of Gabapentin and Trazodone (together) 2-3 hours prior to their
visit
Feline: Please give your patient a sedating dose of Gabapentin the evening before their visit, and 2-3 hours prior
to their visit. Sedation is not necessary for pregnancy ultrasounds
No food for 12 hours prior to appointment. Water is encouraged!
A full bladder is necessary for the appointment, try to discourage urination 1.5 hours prior to appointment
The patient will be shaved for the procedure
Procedure could take 1-1.5 hours. Owner(s) should plan accordingly

Phone

Ultrasound Referral Form

Ultrasound Referral Form

Owner’s Information

Referring Veterinarian’s Information

Pet’s Information

Please fill in history as requested below. Please ensure your client is aware of costs prior to their visit

Once all information is collected, we will contact the owner to set up an appointment.

Offering Accessible Veterinary Care

Location

Contact Information

Hours

After Hours Contact

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