Abdominal Ultrasound Referral Form

When referring your patient to our hospital, please complete this form along with all pertinent medical records.

Date of referral

Today

REFERRING VETERINARIAN INFORMATION

Referring hospital*

Referring DVM*

Phone Number*

Email*

CLIENT INFORMATION

Client's Name *

Phone Number (Primary) *

Phone Number (Alternate)

Client's Email

PATIENT INFORMATION

Patient's Name *

Date of Birth / Age *

Species *

Breed *

Weight *

Sex *

FAS Score *

CASE HISTORY

Presenting Complaint(s) *

Clinical Signs and Duration *

Previous Treatment(s) / Diagnostics *

Please elaborate on any of the conditions above, if needed:

Any increased sedation risk?

UPLOAD DOCUMENTS

Please upload the patient's medical records below. This may include bloodwork, imaging, cytology reports, etc.

Upload Files Here *

Accepted file types: pdf;jpg;jpeg;png;doc;docx.

Before Your Patient’s Ultrasound Appointment

Pre-visit pharmaceuticals (PVPs) are required for all ultrasound patients unless otherwise discussed. Cats should receive Gabapentin 100 mg the night before and the morning of the ultrasound. Dogs should receive Trazodone (5–8 mg/kg) the night before and the morning of the ultrasound.

The referring clinic is responsible for discussing sedation requirements with the client, prescribing the appropriate medications, reviewing sedation risks and obtaining consent, and ensuring fasting instructions are understood.

All ultrasound reports will be sent directly to the referring veterinarian, who will be responsible for communicating results and recommended next steps with the client.

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *