WEEKEND/HOLIDAY

ULTRASOUND REQUEST FORM

* Indicates required field

DATE OF ULTRASOUND *

HOSPITAL NAME *

HOSPITAL PHONE *

DOCTOR REQUESTING THE ULTRASOUND *

HOSPITAL EMAIL *

PATIENT (FIRST AND LAST) *

SPECIES/SEX/BREED/AGE/WEIGHT *

SERVICE *

REASON FOR THE ULTRASOUND *

RELEVANT HISTORY: PROGRESSION OF CLINICAL SIGNS, RESPONSE TO MEDICATION, PE FINDINGS, RADIOGRAPHIC FINDINGS, BLOOD WORK, ECG, BP, ETC. *

We will text the doctor providing services to make sure we can schedule on emergency basis *

yes

for echocardiograms - any ancillary material (rads, BP, ECG) must be emailed to [email protected] by 5 PM on the day of the exam. We can not guarantee the cardiologist will review late submissions. *

acknowledged

Submit

Please consider the following to help us provide the best service:

Have pets dropped off in the morning.
We can not offer specific appointment times for the ultrasounds due to many variables including: number of stops and their locations, last minute emergency add-ons, extra procedures & complications, traffic, weather, etc.

Withhold food for 12-18 hrs prior to the ultrasound (when possible)

Sedation is recommended
When in doubt - sedate. Uncomfortable animals image poorly. Please sedate, when necessary for the sake of the animals comfort and image quality.

Shave in advance
This will help determine which animals will need sedation for the ultrasound.

ULTRASOUND REQUEST FORM

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