Exam request form - mobile veterinary services

ROUTINE OR STAT?*

IF STAT, PLEASE CALL IMMEDIATELY TO SCHEDULE. BASED ON SONOGRAPHER/SPECIALIST AVAILABILITY. 541-357-9423

Services Requested*

Please check ALL that apply. If this is a STAT read, please call immediately so that we can make sure we can accommodate this request.

Abdominal
Echocardiogram Only (No ECG)
Thoracic (WITH Echo)
Double Cavity (Abdominal Plus An Additional Cavity)
Telecytology
Musculoskeletal (Stifles, Shoulders etc.)
Thyroid
Reproductive/Pregnancy Check
Other

Hospital Name*

Overseeing Veterinarian

Patient's First Name*

Patient's Last Name*

Species:*

Breed:*

Patient DOB or AGE:*

Patient Gender:*

Patient Weight:

Clinical Exam Findings:*

Presentation, Physical exam, PERTINENT abbreviated medical history/previous diagnoses only please. Bulleted text format.

ABNORMAL Labratory Findings

Please list most current abnormal lab work values - example: WNL or ALT 400, BUN 47, etc. as well as any increasing or decreasing trends over the past 6 months

Heart Rate and Respiratory Rates*

This is requested by the interpreting cardiologist.

Blood Pressure Measurments*

This is HIGHLY recommended for all cardiac exams, and is routinely requested by our cardiologists.

Current Medications

Any medications patient is currently on, or has been administered in the last 24 hours.

Radiographic Findings

You may send up to 3 CURRENT radiographs that are of the same cavity that is being examined, in DICOM format if at all possible. These will supplement the ultrasound, however the main ddx will be made off the ultrasound itself. Email radiographs to: info@animalsoundsnw.com. If you require a radiograph report, you need to submit the images yourself; contact 800-838-4268 if you need assistance with the procedure.

Primary Question/Differential to Be Answered in This Exam

Have you been able to login to the report portal from Sonopath to view and download your reports?

Sonopath is now posting your ultrasound reports via their reports website at: reports.sonopath.com. Please use your login into that was sent to you to retrieve the report. If you cannot login, please contact ASNW immediately.

Yes
No

Fine Needle Aspirates

At the time of the ultrasound, fine needle aspirates might be indicated, and if approved on-site by Sonopath DVM, can be performed following the ultrasound. However, client permission must be obtained prior to sampling.

Client approved Sedation Only
Client approved Sedation and FNA Consent
Client did not approve sedation nor FNA

Check boxes below if you are emailing radiographs as a supplement to ultrasound only*

If Yes, Please email them to info@animalsoundsnw.com Note: Radiographs in DICOM (.dcm) format if at all possible.

Emailing Supporting Radiographs
Other
Nothing to Email

Notes to the Sonographer (NOT to be put on report anywhere)

If you have anything you want to pass on to the sonographer re: the case, pet, or client that you want to remain confidential, please provide that here. Will NOT be put on the report 🙂

Your Email For Submisson Form Confirmation*

This is NOT necessarily what email address the report will come to.. the report will be posted to your report portal and an automated email will be sent to the email address you provided on your account

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