Referring Doctor *

Referring Veterinary Hospital *

Email *

Phone *

Fax Number for Report *

Client (Owner) First Name *

Client (Owner) Last Name *

Client (Owner) Address *

Client (Owner) Phone *

Client (Owner) Email

Patient Name *

Species *

Breed *

Sex *

Reproductive Status *

Patient Date of Birth *

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

Does this patient have any medical reason to not sedate and/or perform fine needle aspirates if indicated? *

Yes

No

If yes, please explain why.

Should a mass or lesion be found, and we are granted client consent, would you like us to obtain a FNA? *

Yes

No

Does your patient have any drug allergies and if so please explain? *

I am referring this patient for *

Abdominal ultrasound

Echocardiography

Thoracic ultrasound / other

w/ FNA

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Outpatient Abdominal Ultrasound Referral Form

New Patients Welcome