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Minneapolis, MN

Pet Ultrasound Referrals

For non-urgent and stable patients referred solely for ultrasounds, it is essential that the referring veterinarian submits the required form before scheduling their appointment.

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Referring Veterinarian's Name *

First

Last

Clinic Name *

Referring Veterinarian's Email *

Client's Name *

First

Last

Client's Cell Phone *

The client will automatically receive a one-time SMS text message that we have received your ultrasound referral and asks them to check the provided email for detailed instructions. The client can reply STOP at any time to opt out.

Client's Email *

The client will automatically receive an email that we have received your ultrasound referral along with detailed instructions.

Patient's Name *

Species *

Canine
Female

Approximate Weight

Sex *

Age/Date of Birth *

Mandatory Client Awareness

Client must be made aware of every topic prior to being referred to VSC for a non-urgent ultrasound.

Client has been informed of $550 ultrasound fee. *

Yes, client has been made aware

This patient needs to have been fasted for 12 hours prior to the non-urgent ultrasound. *

Yes, client has been made aware

Client is aware that you, their primary veterinarian, will be responsible for reviewing the ultrasound findings and discussing the next steps. *

Yes, client has been made aware

Patient may need to be sedated for safety and/or diagnostic accuracy reasons (there will be additional fees for sedation). *

Yes, client has been made aware

Medical Information

Reason for Non-Urgent Ultrasound *

Primary Problem(s) *

Pertinent Medical History *

Diagnostic Tests Performed/Results *

Type NONE if applicable.

Current Medication *

Type NONE if applicable.

Previous surgical and/or other procedure(s) and date(s)

Upload Any Files (records, labs, radiographs, ultrasounds, MRIs, CTs, etc.)

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Please upload a one-year history, current blood work, imaging, and any other relevant information.

Minneapolis, MN

Pet Ultrasound Referrals

Mandatory Client Awareness

Medical Information

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