Outpatient Ultrasound Request
Please see sedation protocol here

To be filled out by requesting veterinarian

Patient (Pet) Name

Client first and last name

Species

Dog

Cat

Other (please call to discuss case)

Breed(s)

Age

Sex

Client Phone Number

Primary Veterinarian Name

Primary/ Referring Vet Hospital

Primary/ Referring Vet Hospital Email Address

Any additional email address you would like report sent to

Current History/ Reason for Ultrasound:

Prior and/or Chronic Medical Conditions:

Pertinent lab work abnormalities:

Prior Ultrasound?

Yes (please email prior report to ange@mwvi.vet)

Recent radiographs?

Yes (please email them to ange@mwvi.vet)

How would you like to be contacted with results if findings are urgent?

Primary Veterinarian Direct Phone Number (in case of urgent results)

Would you like FNA performed if a lesion is found and deemed appropriate to sample?

Yes, if client agrees

No, we do not want FNA

If FNA performed, cytology submission preference: