Outpatient Ultrasound Request Form

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/ Referring Veterinarian Name

Primary/ Referring Vet Hospital

Primary/ Referring Vet Hospital Email Address

Please provide any additional email addresses where you would like the report to be sent.

Current Medical History/ Reason for Ultrasound:

Please list any prior or chronic medical conditions.

Please list any pertinent lab work abnormalities:

Will the patient be given any sedatives prior to the ultrasound?

Yes, they will given oral sedatives.

No, please give injectable medications if necessary. I have discussed this with the client.

Please click the link to see the suggestions for oral sedatives. Outpatient Sedation Protocol

Please indicate if there were any prior ultrasounds performed.

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

No

Please indicate if there were any prior radiographs taken.

Yes (please email them to info@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 an like FNA performed if it is deemed appropriate to sample?

Yes, if the client agrees

No, we do not want an FNA

If an FNA is performed, please indicate the cytology submission preference: