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Ultrasound Referral Form
This form must be completed by the referring veterinarian, and will be automatically submitted via email to info@phasesvetemerg.com. Our team will review the referral and contact you to let you know whether it has been accepted. We will then contact your client directly to schedule their scan. Following their scan, the report will be sent back to your clinic for you to share with your clients. The form must be filled out IN FULL, to avoid any delays in the referral process. Thank you.
Referral Date
*
Date Format: MM slash DD slash YYYY
Referring Veterinary Information:
Referring Clinic
*
Referring Veterinarian
*
Please select which services you are referring for:
Abdominal Ultrasound – includes full abdominal scan, 2D measurements, colour flow doppler and DVM report.
Abdominal Ultrasound with Radiologist Report
Echocardiogram – Include 2D measurement, B-mode, M-Mode, colour flow doppler and spectral doppler measurements, ECG – lead 2, cardiologist report.
Double cavity U/S with cardiologist report and DVM report for abdomen recommendations
Double cavity U/S with cardiologist and radiologist report
Pregnancy ultrasound (21 days after insemination)
Follow up abdominal ultrasound (must be within 60 days of initial study)
Follow up echocardiogram (must be within 60 days of initial study)
Add on FAST/TFAST/Focal Organ/System – single organ, cavity scan (urinary, pericardium, heart base/right atrium, neck, MSK) when added to the main study (AUS or Echo)
FNA under U/S guidance one organ (liver, lymph nodes, spleen, pancreas, gallbladder) – RDVM/Clinic will add on the cost for cytology to lab.
FNA under U/S guidance multiple organs – RDVM/Clinic will add on cost of cytology for reference laboratory (True North, Idexx, Antech).
Add on teleradiology on certain/specific cases with radiologist or cardiologist report/assessment/ recommendations.
Sta ‘Pet Ultrasound
APPT and PT Coagulation Factors
Phone
*
Email
Client/Patient Information:
Owner Name
*
Contact Number(s)
*
Email
Patient Name
*
Species
*
Breed
*
Age
*
Sex
*
M
MN
F
FS
Patient Behaviour (Easy to Handle?)
*
Tentative Patient Diagnosis
*
Reason for Ultrasonography
*
Reason for Fine Needle Aspirates or Core Biopsies?
*
Are Cytology or histopathology services needed (generally sent to IDEXX)?
*
Yes
No
CBC and COAGs may be requested prior to FNA/biopsy. Can this be completed by your clinic within 72 hours of the appointment or should our team book this at our hospital?
*
rDVM will complete
Request PVEH to complete
Timeline for referral:
*
Urgent
Next Available
*If you request "urgent" this would mean we may reschedule another booked patient to fill this patient in, so please only select if truly urgent.
Please acknowledge:
Will the patient be on pre-visit gabapentin or trazodone?
*
Yes - Gabapentin
Yes - Trazodone
No
My client is aware that full sedation may be recommended/required.
*
Yes
No
My client is aware that their pet's fur will be clipped for the scan.
*
Yes
No
My client is aware that they cannot be present for the scan.
*
Yes
No
If applicable: Risks of FNA or Core Biopsy collection have been discussed with my client.
Yes
No
Costs associated with the scan, possible sedation, sample collection and sample send off have been discussed with my client.
*
Yes
No
Current Medications:
*
(Include dosage, frequency, dates started, include all medication pet is currently taking including supplements, holistic therapy etc.)
List any recent or related Surgeries or other conditions our team should be aware of:
*
Any history of complications from anesthesia or sedation?
*
Is there any other pertinent information you wish to share with our team, or any further requests?
Signature of referring DVM:
*
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