Outpatient Ultrasound Form

Outpatient Ultrasound Form

Referral Information

Information

Client (Owner) Name *

Patient Name *

Species *

Sex *

Referring Veterinarian *

Contact number to be immediately reached at conclusion of ultrasound *

Pertinent History

Clinical History (primary reason for imaging, physical exam findings, recent lab work [within 30 days] pertinent medical history, etc.) *

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Important Information About Ultrasound Only Appointments

Food should be withheld for 12-15 hours prior to the procedure for optimal image quality. If this is not possible for medical reasons, please contact us. Withholding water is not necessary.

For ultrasonographic procedures, the area of interest will be shaved to optimize image quality and maximize the diagnostic potential of the test.

Owners will not be given the results of the imaging procedures performed except under certain, critical circumstances. The owners will be asked to contact your office for imaging results, and to make plans for further actions. This is to keep you in control of your case and to simplify communications.

If you wish to have another doctor at our facility go over the imaging results with the owner, a consultation with the Internal Medicine department or the Emergency department must be scheduled in conjunction with the ultrasound only appointment. Please contact us to schedule the appropriate consultation.

Biopsies, needle aspirates and other interventional procedures are not scheduled as outpatient procedures and cannot be performed as an add-on to an ultrasound only appointment. Routine, non-emergent procedures can be scheduled through the Internal Medicine department as consultations. Please contact us for more information.