Outpatient Ultrasound Request

A completed outpatient Ultrasound request form is required prior to making an appointment for outpatient ultrasound.

Once we receive your referral request, a MASH team member will contact the pet owner to schedule an appointment.

"*" indicates required fields

Are you wanting a consultation & assessment by a Small Animal Specialist Surgeon?

Yes

Based on your answer to the above question, you need to fill out this form instead.

Referring Veterinarian*

First Last

Referring Vet Clinic*

Referring Veterinary Clinic Email:*

Owner Name*

First Last

Owner Phone Number*

Owner Email*

Patient Name*

Patient Species*

Patient Breed*

Patient Weight*

Patient Age*

Reason for abdominal ultrasound*

Are there any contraindications for sedation or general anaesthesia:*

Yes

If there are contraindications please note here:

NB: CT is more sensitive than ultrasound for lesion detection in patients over 25 kg. For patients over 25-30 kg, depending on the reason for ultrasound examination request, CT may be a more sensitive test.
2012 Sep-Oct;53(5):513-7. doi: 10.1111/j.1740-8261.2012.01949.x. Epub 2012 May 22.
Comparison of abdominal computed tomography and abdominal ultrasound in sedated dogs, Erica L Fields 1, Ian D Robertson, Jason A Osborne, James C Brown Jr.

Have there been any abnormal CBC or biochemistry or other laboratory tests within the last 12 months?*

Yes

If Yes, please note here:

Upload the clinical history:*

Drop files here or

Accepted file types: jpg, jpeg, dicom, pdf, Max. file size: 128 MB.

Outpatient Ultrasound Request

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