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Referral form below
SonoPath Imaging Center Patient Submission Form
"
*
" indicates required fields
Date
*
MM slash DD slash YYYY
Doctor/ Hospital Information
Referring Hospital
*
Referring Doctor
*
Hospital E-mail for report notifications
*
Hospital Address
*
Hospital E-Mail
*
Hospital Phone Number
*
Owner Information
Owner Name
*
First
Last
Owner Email
*
Owner Phone Number
*
Patient Information
Patient Name
*
First
Last
Species – K9 – Fel – Other (Specify)
*
Age (years)
*
Breed
*
Weight (lbs)
*
Sex
*
Male
Female
Is your pet spayed or neutered?
*
Yes
No
Animal's Temperament
*
Friendly
Caution
Go Slow
Painful
Feral
Please choose one or more to describe the animals temperament
Medical reason for imaging
*
Current Medications
*
History of medication allergies, sedation/anesthesia reactions, etc.
*
Please select below what we will be scanning
CT Note cavity to be imaged (Check all that apply)
*
N/A
Head
Dental only
Thorax
Abdomen
Abdomen Portosystemic Shunt
Abdomen Ectopic Ureter
Pelvic Cavity
Elbows
Shoulders
Pelvis
Stifles
Neck (Soft Tissue)
Spine – Entire
Spine – Cervical
Spine – T3-L3
Spine L3-S4
Other (Please Specify)
If "Other" is selected please specify here
Ultrasound Note cavity to be imaged (check all that apply)
*
N/A
Abdomen
Echo
Echo Cardiologist Read
Comprehensive Echo (Referring Hospital must provide BP and EKG)
Thorax (Non-Cardiac)
Thyroid
Stifles (Bilateral)
Achilles (Bilateral)
Stat
Additional Procedures:
*
N/A
US-Guided FNA
Biopsy
Drainage Procedures
Centesis
Bone Marrow Sampling
US-Guided Traumatic Catheterization
Have you discussed with the owner, potential FNA for cytology sampling based on findings?
*
Yes
No
Do we have permission to do an FNA if necessary?
*
Yes
No
Additional Notes
Other diagnostic imaging/procedure reports completed in the last 6 months:
Specify other diagnostic/ imaging completed
*
ECG Report
Rad Report
FNA/Biopsy Report
Ultrasound Report
Endoscopy Report
Not Applicable
Other
Other diagonstic(s) not listed
PLEASE NOTE any internal organs previously removed
Supporting reports from other diagnostic imaging/procedures (within the last 6 months)
Drop files here or
Select files
Max. file size: 50 MB.
REFERRING VETERINARIAN: Confirm you have downloaded the pre-visit instructions for you and your client
*
Yes
No
(2 forms: Referring Veterinarian Instructions & FAQ’s and Pet Owner Appointment Instructions)
Ready to upload files? Please include the following:
Full exam/medical history (must have been completed within the last 4 weeks)
*
Max. file size: 50 MB.
CBC/Chem/U/A (must have been completed within the last 4 weeks)
*
Max. file size: 50 MB.
If unable to upload, please email
[email protected]
After the referral form is submitted and reviewed, you will be contacted within 24 to 72 hrs by the Imaging Center staff.
After submitting form you will be directed to a confirmation page.
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