Ultrasound Referal Form

Please complete this form at least 24 hours prior to the appointment and ensure you have notified the client of the following:

  • Patient should not be fed within 12 hours of the scheduled appointment
  • Patient should not be allowed to urinate within 2-3 hours of the appointment
  • Patient may need to be sedated to obtain diagnostic images
  • Client has been given an estimate of cost (please call for more information if needed)
  • Client will receive results via their regular DVM, typically within 24-48 hours of the appointment

Which practice would you like to register with?

 

REFERRING HOSPITAL INFORMATION

Referring For*:
 
*PLEASE NOTE: For Echocardiogram, all cats must be prescribed Gabapentin to be administered the night before and 2 hours prior to scan in order to reduce the need for sedation.

CLIENT INFORMATION

PATIENT INFORMATION

Patient Should Be Seen (if possible):

**Patient history must be provided prior to the ultrasound date**

 

Patient History may include:
1. Medical Records
2. X-rays
3. Lab Results
4. Other Documents

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