Patient Information

Patient Name *

Breed *

Age *

Sex *

Neutered *

Yes
No

Client Information

Client Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Phone number where you can be contacted during your pets procedure

Email *

Referral Information

Referring DVM name *

Clinic Name *

Clinic Contact Phone *

Clinic Contact Email *

Referral for: *

Abdominal Ultrasound
Thoracic/neck Ultrasound
Echocardiogram / Cardiac Ultrasound‬ ‭

Patient History

This information will help us formulate history for submission to a radiologist.‬

Problems/concerns/reason for referral: *

Historical concerns: *

Current medications (please included doses and frequency, especially for echo referrals): *

Abnormal physical exam findings: *

Labwork results: *

Imaging results: *

Differential diagnoses:‬ ‭ *

Specific questions to be addressed: *

Known medication/sedation sensitivities, or preferred sedation if needed: *

Questions for abdominal ultrasound referrals:‬ ‭

Approved procedures:

FNA
TrueCut Biopsy
Abdominocentesis

Any patient undergoing biopsies or FNAs should have a recent CBC showing adequate platelet levels.
If liver disease is a concern and liver FNA or biopsy is indicated and pursued, then a‬ PT/PTT will be required and can be formed at the time of the ultrasound if the primary‬ clinic does not have access to this test.‬

Questions for thoracic/neck ultrasound referrals:

Approved procedures: lung/lymph node/mass FNA

Yes
No

Questions for echocardiogram referrals:

Murmur grade, location, timing (if present)

Blood pressure

ECG rhythm

Current symptoms:

Collapse
Syncope
Ataxia
Coughing

Approved procedures:

Pericardiocentesis
Pleurocentesis

Notes:

We will always discuss the procedure with clients in person before they drop their pet off with us.
We require a 100% deposit for the cost of the procedure prior to performing the procedure. We will provide an estimate to you and the client prior to the procedure.
All patients will be shaved for their ultrasound. For abdominal ultrasounds, the patient will be shaved from xiphoid to pubis and from left mid-lateral to right epaxials. For thoracic ultrasounds, the chest will be shaved as needed to answer the question. For echocardiograms, the chest will be shaved on either side just behind the shoulders where the elbow touches the chest, and just caudal to the xiphoid.
Most patients will be sedated. They are being held in awkward positions for 15-30 minutes in most cases so sedation is usually kind to provide. All clients must agree to the use of sedation as necessary. Sedation for echocardiograms will include Butorphanol +/- Alfaxalone as they do not measurably alter cardiac function.
Any patient with moderate to severe peritoneal effusion will need abdominocentesis (can be done at time of imaging) prior to obtaining imaging as it will likely increase the quality of the ultrasound.

Forms

Outpatient Ultrasound Form