Ultrasound - CVETS - Columbia Veterinary Emergency Trauma and Specialty

Clinic Name*

Primary Veterinarian's Name*

Pet Owner's Name*

Patient Name*

Best Phone Number To Reach You*

Upon arrival, the client and pet will be greeted by the CVETS radiologist's assistant. If the pet appears to require medical attention, the radiologist will contact you to determine if the pet should be triaged by a CVETS emergency doctor or referred back to your practice for further evaluation. If the patient appears in critical condition, the radiologist will have the pet evaluated by a CVETS emergency doctor immediately. By submitting this form, you have agreed to these terms.

Pet Owner's Phone*

Pet's Age, Sex and Breed*

Clinically Relevant History*

Working and Prior Diagnoses*

Type of Ultrasound*

Abdominal
Non-Cardiac Thoracic
Neck
If other Please explain

Other Type Explanation*

What are your main clinical questions for the radiologist?*

Do you anticipate sedation being needed to complete the exam?

Yes
No

Explanation*

Are there any contraindication for sedation?*

Yes
No
N/A

Have you consulted with another CVETS veterinarian about this case?*

Yes
No

CVETS Veterinarian Name*

Outpatient Ultrasound

Outpatient Ultrasound