Indicates required field

Referring Veterinarian

Requesting Clinic:

Requesting Veterinarian:

Requesting Veterinarian or Clinic Phone:

In case our sonographer has additional questions.

Requesting Veterinarian Email:

This is the email address the report will be sent back to.

Please inform your clients that YOU will receive the results within 24 hours after the ultrasound is completed.

Client Information

Client First Name

Client Last Name

Email Address:

Client Phone Number

Patient Information

Patient First & Last Name:

Patient Age:

Patient Species

Patient Breed or Breed Mixes:

Patient Sex:

Patient Weight (lbs):

Patient is Spayed/Neutered

Yes

Sedation Protocol

Please choose your preferred sedation protocol

Butorphanol Only

Dexdomitor + Butorphanol

Dexdomitor + Butorphanol + Ketamine (Felines)

ZenAlpha (Canines)

ZenAlpha + Butorphanol (Canines)

Butorphanol + Midazolam

Other, please provide details:

I typically avoid hydromorphone due to the increased panting, and acepromazine due to the secondary splenomegaly but will use these medications if specifically requested.

Please list any medications that are contraindicated should the sedation protocol need to change due to patient behavior:

Post-Sedation Take Home Instructions

Post-sedation Diet (please choose one):

No diet restrictions

Offer ¼ the amount of your pet’s normal meal quantity. If you pet does not vomit, you may feed normally

Per your veterinarian’s recommendation, please keep your pet fasted overnight in case the ultrasound results indicate surgery is needed.

Other…

Clinical History

Clinical History (or Clinical Update for repeat studies):

Please provide the clinical history leading to an ultrasound being indicated for this patient. If you do not wish to type out your clinical history, it may uploaded below.

Clinical History Upload:

Labwork may be uploaded here or seperately below.

Unlimited number of files can be uploaded to this field.
100 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Any specific concerns you want to see addressed by the radiologist (not visible on the report):

Please upload all pertinent lab work:

NOTE: All provided labwork results will be attached. Radiographs provided will NOT be submitted with the ultrasound (as interpretation of the radiographs is NOT included in the cost of the ultrasound interpretation).

Unlimited number of files can be uploaded to this field.
100 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Any additional questions, comments, or concerns (optional):

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Ultrasound Referral Form Swann Animal Clinic

Referring Veterinarian

Client Information

Patient Information

Patient Specific Concerns

Sedation Protocol

Post-Sedation Take Home Instructions

Clinical History

How Are We Doing?

How Are We Doing?

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