Ultrasound Referral Form

Which practice would you like to register with?

Location

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Date of referral

Today

Request for appointment*

Immediate (within 48-72 hours)
Urgent (7-14 days)
Non-Urgent (next available)

REFERRING VETERINARIAN INFORMATION

Referring hospital*

Referring DVM*

Phone Number*

Email*

PATIENT INFORMATION

Pet Name*

Species*

Breed*

DOB/AGE*

Gender*

Weight (Please provide in kg) *

CLIENT INFORMATION

Owner's Name *

Co-Owner's Name

Address

City

Province

Postal Code

Phone Number *

Secondary Phone Number

CASE INFORMATION

QUESTIONS YOU WOULD LIKE ANSWERED*

LIST OF CURRENT MEDICATIONS/DOSAGES*

HISTORY/PHYSICAL EXAM FINDINGS*

Summary of bloodwork results, history, clinical signs, physical exam. The more detailed the information the better the study.

BLOODWORK / RADIOGRAPHS

Please share with us any lab results or radiographs for this patient by uploading the files below.

Files Uploaded

Bloodwork (done within last 6 months)
Radiographs
Medical History
Other

If other, please specify

PLEASE NOTE

Ultrasound is a non-invasive imaging modality that allows us to see organs in real time in a safe, comfortable environment for your pet. Although ultrasound can give us valuable information, it is important to note that a negative ultrasound does not rule out pathology, meaning if we do not find anything significant on our ultrasound that does not rule out a disease process occurring in your pet.

Please understand that Dr. Alexandra Dooley is not a board certified ultrasonographer, but has undergone significant continuing education in the area of ultrasonography in order to perform these procedures. Should you like to have the images reviewed by a board-certified specialist, or should Dr. Dooley feel that it is necessary, there is an additional cost which will be discussed prior to sending the images away.

In order to obtain clear images, the patient will need to be fasted from food for 8-10 hours prior to the procedure. The patient will need to be sedated for the procedure and their abdomen/chest will be shaved to allow for better contact between their skin and the ultrasound probe to achieve the best images possible.

I have read and understand the above note*

Security Question*

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY **

Ultrasound Referral Form

Which practice would you like to register with?

REFERRING VETERINARIAN INFORMATION

PATIENT INFORMATION

CLIENT INFORMATION

CASE INFORMATION

BLOODWORK / RADIOGRAPHS

PLEASE NOTE

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