Ultrasound Request Form

Referring Clinic
Clinic Telephone Number
Referring Doctor
First Last
E-mail for Results
Client Full Name
First Last
Phone#
Patient Name
Species
Breed
Age
Sex
Weight
To ensure proper patient care during the ultrasound examination, please identify any known medical conditions:
- Heart Murmur
- Chronic Renal Disease
- Seizures
- Previous Adverse Drug Reactions
If any previous adverse drug reactions please specify:
Ultrasound study requested
- Full Abdomen
- Urinary system (bladder, kidneys, cystocentesis)
- Single Organ
- AFAST/TFAST and fluid collection
If single organ selected please specify:
Estimate:
History and Clinical Signs:
What questions would like answered:
• Please ask that the patient be fasted for 12 hours • Encourage pet to have a bowel movement prior to admission • Prepare for a minimum of 6 hour hospitalization • Due to sampling handling procedures no urinary cases are to be performed on Fridays.

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