Outpatient Ultrasound Request

Please call us at (352) 225-3501 if you have any questions while filling out this form

Requesting DVM Name:

DVM Phone number:

DVM Email address:

(You will also receive a copy of this request.)

Name of Pet Owner:

Owner's Cell Phone Number:

Owner's Email Address:

Name of Pet:

Species:

Breed:

Age of Pet:

Is Pet a Male or Female?

Has this pet been spayed or neutered?

Study Requested:

Abdominal Ultrasound

Other:

Cervical Ultrasound:

Is this Ultrasound URGENT? (If yes, an emergency consult fee may be added if the patient requires immediate medical intervention.)

Yes

Clinical History:

Specific concern for the current study and questions to be answered by the Radiologist:

We recommended that the referring veterinarian prescribe anxiolytic medications to be given the night before and morning of the appointment. (If you would like a recommended sedation protocol, feel free to contact us via phone or email prior to the ultrasound appointment.).

Anxiolytic medications prescribed:

Please upload patient's records here

If records are not attached, please email to reception@ccvetspecialists.com

Delete all uploads

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Patient preparation:

Patient must have had a physical exam by a veterinarian within the past 30 days

All patients over 6 mo should be fasted after midnight the night prior to the exam

(water is allowed, give routine medication as prescribed).

Sedation or General Anesthesia may be necessary to perform the study. Please list any known medication reactions or contraindications (heart disease, kidney injury):

Is Ultrasound guided fine needle aspiration requested?

Yes

If warranted

***Please be advised that in order to ensure your patient is a good candidate for ultrasound guided aspirates, a CBC/PT/PTT is required prior to the ultrasound appointment. These labs will need to be run within two weeks of the scheduled ultrasound. It is preferential for these labs to be run prior to the appointment, however, if this is not possible or has not been received, the lab work can be performed at CCVS on the day of the ultrasound.

CBC/PT/PTT will be run with the referring veterinarian and sent to CCVS prior to the appointment. It is the responsibility of the referring veterinarian to schedule this for the patient prior to the ultrasound.

Lab work will be run at CCVS on the day of the appointment.

***Are there any specific requests for ultrasound guided FNA's or tissue sampling? (The radiologist will use best judgement when sampling.)

Communication of imaging findings:

Please note - this is an outpatient procedure. We will send results of the ultrasound, and any sampling, to the referring vet to be relayed to the owner.