Ultrasound Request
Referring Vet Name
Full name of the referring veterinarian
Phone Number
If NOT an Australian phone number, please include country code
Email
Vet Clinic
Proposed date & time for booking (subject to availability)
Date
Time
Morning : 8.00am-Noon
Afternoon : 1.00-5:00 pm
What time is best to call you back?
Patient No.
Patient Clinic Identification Number
Patient Name
Owner's Name
Patient Date of Birth
Species Type
Choose one
Canine
Equine
Feline
Exotic
Avian
Bovine
Caprine
Other
Patient Sex
Choose one
Male Neutered
Female Speyed
Male Entire
Female Entire
Patient Sex
Choose one
Stallion
Gelding
Mare
Colt
Filly
Patient Sex
Choose one
Male
Female
Desexed Male
Desexed Female
Patient Sex
Choose one
Male
Female
Patient Sex
Choose one
Bull
Cow
Heifer
Steer
Patient Sex
Choose one
Buck
Doe
Wether
Breed
Ultrasound Site(s)
Abdomen
Cardiac
Thorax
Musculoskeletal
Other
Other Ultrasound Site(s)
Presenting Signs and Duration
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Clinical History
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Specific Questions, Concerns, DDx rule outs
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Is a previous study available?
Yes
No
Date of previous study
Please send the most recent previous study to ImagingVets PACS