Ultrasound Referral

You may either download the form to fill out and fax into us by clicking here (fax number is on the download) or fill out the form below.

Referring Veterinarian
Hospital
Phone
Fax
Date Exam Requested
Client Name
Phone Number
Pet's Name
Age
Breed
Sex
Presenting Complaint/History
Current/Recent Medications
Lab Results/Tests Pending
Radiographic Findings
Please send radiographs with client for best case management.
Diagnosis or Rule-Outs
Ultrasound Requested
Additional Tests Requested
Is anesthesia/sedation possible if needed (or indicate if you know it will be necessary). Also please note any limitations or previous problems with anesthesia.
Anesthesia Notes
Ultrasounds are scheduled according to availability for the date requested. Additional tests may require pre-anesthetic bloodwork including clotting profiles, SAP, CBC, etc.Dr. Dasher will need to discuss the case with the referring veterinarian prior to ultrasound date to ensure that tests requested are possible and yield best results.
Please advise your clients that we do not accept checks