General Ultrasound Referral Form

Please complete this form at least 24 hours prior to the appointment and ensure you have notified the client of the following:

  • Patient should fast for 8-10 hours prior to their appointment, access to water is allowed
  • Patient should not be allowed to urinate within 3-4 hours of the appointment
  • Patient will be shaved and may need to be sedated to obtain diagnostic images
  • Oral anti-anxiety medications (ie trazodone, gabapentin) have been discussed and prescribed if for high energy, nervous or aggressive patients
  • Client has been given an estimate of cost (please call for more information if needed)
  • Client will receive results via their regular DVM, typically within 24-48 hours of the appointment. Grand Valley Animal Clinic will not discuss ultrasound results with the client.

REFERRING HOSPITAL INFORMATION

Referring For *

CLIENT INFORMATION

PATIENT INFORMATION

Patient Should Be Seen (if possible)
If a mass is found, do you request for an FNA to be performed? *

**Patient history must be provided prior to the ultrasound date**

 

Patient History may include:
1. Medical Records
2. X-rays
3. Lab Results
4. Other Documents

Security Question *