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Outpatient Ultrasound Referral Form

Fill out the Outpatient Ultrasound Referral form below

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For a printable version of this form, click here.

Non-Emergent Abdominal Ultrasound Request

We will contact your client within 3 business days to schedule the appointment.

These outpatient studies do not include a consultation or additional diagnostic testing. Sedation is not administered for outpatient imaging studies; however, patients may be premedicated prior to arrival at the discretion of the referring veterinarian. If sedation is anticipated to be necessary for the examination, please submit the referral through our Emergency or Internal Medicine service instead.

Results will be sent to the referring veterinarian within 24 hours of the examination.

Outpatient Ultrasound Referral Form
Sex
Altered
Is the pet up to date on their vaccines?
Owner's Name
Owner's Name
First
Last
Address
Address
City
State/Province
Zip/Postal

Please send copies of medical records, radiographs, and lab results via fax or email.

Referring Veterinarian Information

Referring Veterinarian
Referring Veterinarian
First
Last
Address
Address
City
State/Province
Zip/Postal
In order to continue with the scheduling process, we need all medical, imaging, etc reports sent to us. How would you prefer to send them?

Maximum file size: 52.43MB

I agree to send all medical records to info@vcsgvets.com and I understand that the client will not be scheduled until the records are received.