Ultrasound Request

Note for veterinarians

Once an ultrasound has been scheduled, this form should be filled out as soon as possible and at least 24 hours prior to the appointment.

- Please remember to have the patient fasted 12 hours prior to examination unless this is not clinically safe (pediatrics, diabetic patients, etc). Also prepare the clients for their pet to be shaved and obtain to permission to sedate if necessary to maximize the quality of the study and information obtained.

Ultrasound Request Form

Hospital Name *

Phone Number *

Attending Clinicians *

Patient Name *

Client Last Name *

Patient ID# (ID number from your practice management software) *

Patient Weight (kg) *

Date of Birth (MM/DD/YYYY) *//

Sex *

Spayed/Neutered? *

Species *

Breed (Optional)

Study Requested *

Is an appointment scheduled? *

Scheduled Date of Study (MM/DD/YYYY) *//

Are fine needles pre-approved by owner? *

Will urine collection via cystocentesis be needed? *

If abdominal effusion is present, do you want sample collection? *

Has sedation been discussed with owner? *

Brief case summary/other requests (PLEASE BE BRIEF):

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