Veterinary Hospital
*
Location of Ultrasound
Requesting hospital
VCA CAVES
VECM
Other
Location if "other"
Veterinarian Requesting the Procedure
*
Requested Date for Ultrasound if Known
MM
DD
YYYY
Pet Name
*
Client Last Name
*
Species
*
Select
Dog
Cat
Breed
*
Gender
*
Select
Male Intact
Neutered Male
Female Intact
Female Spayed
Date of Birth
*
MM
DD
YYYY
Age
Patient Weight in lbs.
Procedure Requested
*
Examples: Abdominal ultrasound, Echocardiogram, Thoracic ultrasound, Bicavitary ultrasound, Single system ultrasound, Pregnancy ultrasound, Fine needle aspirate, etc.
Reason for Ultrasound
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Concise history when possible. Include presenting clinical signs. Please do not write "See Record".
Pertinent Laboratory Findings
Please include numerical values for abnormal results and include DATES.
Please do not send labwork in lieu of including pertinent details in this form. Please do not write "see record/chart".
Current Medications
Diet
Patient Behavior
*
*If you suspect this patient may be tense, nervous, or aggressive during the exam, please consider prescribing an oral sedative (such as gabapentin or trazodone) to be given at home prior to the procedure.
Additional Behavior Notes
Sedation
*
Sedation is strongly recommended for any pet that is unlikely to lie quietly on their back with a relaxed abdomen. This allows for better imaging quality and a safer experience. Sedation is particularly beneficial for excited puppies and large breed dogs.
**Oral sedation is strongly advised for outpatient ultrasound at CAVES or VECM. If injectable sedation is required, rescheduling of the appointment may be necessary.
Fine needle aspirates and cytology
The referring doctor or hospital should discuss the possibility of FNA in cases likely to warrant the procedure. Patients should have a CBC within the past 7 days, and clients should be aware of risks (including ~5% chance of bleeding). Patients with potential mast cell disease should receive diphenhydramine the morning of the procedure or immediately prior.
Please provide an estimate to the owners prior to the ultrasound that includes the cost of aspiration, cytology, and additional sedation (in case needed).
Name of person completing this form
*
Thank you for your submission! Referral forms allow us to provide more complete recommendations for your patients. We are so appreciative of your time and effort!
If you have made any mistakes or need to add something, please feel free to submit a new form, but please write "revised" after the patient's name. This form is informal and is not saved beyond the exam.
