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Outpatient Ultrasound Request Form
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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)
No
Recent radiographs?
Yes (please email them to ange@mwvi.vet)
No
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
Submit Request
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