Ultrasound Referral Form in Bedford, Nova Scotia

Referral Service:

Abdominal ultrasound:
Other

Abdominal ultrasound:

Explain other:

Referring Hospital:

Veterinarian:

Phone Number:

Fax:

Email:

Client Information

Name(s):

Address

Street Address

Contact Number:

Email

Patient Information

Name:

Species:

Breed:

D.O.B:

Sex:

Neutered/Spayed:

Colour:

Weight:

Relevant History:

A 12-hour fast period is recommended prior to the ultrasound. Water is allowed and if possible, we would like a full bladder.

Please fax or email referral with a brief case summary and recent medical notes, including any diagnostics pertinent to the history.

Please inform clients that their pet will have their abdomen shaved and may also be given sedation prior to the ultrasound.

Thank you for entrusting us with the care of your patient. I would like test results sent to me via: Email

Date