InstagramThis field is for validation purposes and should be left unchanged.Referring Hospital:*Referring Veterinarian:*Referring Hospital Phone Number:*Referring Hospital Email:* Status of Request Routine STAT Service Requested* Abdominal Ultrasound Echocardiogram - ABVP Specialist Interpretation Echocardiogram - Cardiologist Interpretation ($55 more) Bicavity (Abdominal Scan and Echocardiogram) Other (Thorax, Orthopedic, Small Parts, Mass, etc.) FNA (Fine Needle Aspirate) - if indicated Pet's Name:*Client's Last Name:*Species* Canine Fenine Breed*Age*Weight (please list lbs or kgs):*Gender* Female Intact Female Spayed Male Intact Male Neutered Clinical History:*Abnormal Physical Exam Findings:*Abnormal Diagnostic Findings:*Please add your primary concerns below so we can be sure to evaluate the patient most effectively for your work up:***Clipping and Sedation** Please advise your client that the pet will likely need to be clipped and lightly sedated. We want the pet to be as comfortable as possible as tense, panting, or nervous animals often make it more challenging to obtain optimal views and complete scans. Clipping - clipping of the fur allows for better contact with the probe to the patient significantly improving imaging. Please be sure to inform your client that their pet will require clipping to optimize imaging.Sedation - Sedation of the pet allows for better contact with the probe and relaxed muscles improve our ability to collect the best images possible. We strongly advise for the pet to be sedate to improve the ability for us to obtain the best imaging possible. Many patients do well with pre-visit medications like Gabapentin +/- Trazodone 2-3 hours before. A number of pets require injectable sedation. At your request, we can forward our recommended mediations for an ultrasound. Sedation is REQUIRED for Fine Needle Aspirate Sampling. Please select the option the client consented to below:* Client approved sedation Client did NOT approve sedation