Referral Form Radiology Outpatient Ultrasound Service *Dr Rajdeep Multani, DVM, DACVR Referring veterinarian's name Referring Clinic's name Referring Hospital's phone number Referring Hospital's email Owner's name Owner's phone number Owner's email Patient's name * Species * SpeciesCanineFelineOther Breed * Sex * SexMMNFFS Patient's weight Please indicate the reasons for the referral Concern duration Relevant medical history summary: Hello Physical Exam (Specify exam dates and main findings only) Rectal performed Yes / No (Findings?) Laboratory Tests: (Attach results if available) UploadPatient file, blood results, other files...Accepted files : jpg, jpeg, jpe, gif, png, ico, js, tar, xcf, docm, xlam, numbers. Max. file size: 10 MB Recent CBC: Recent CBC: Yes No If yes, describe main abnormalities including values Chemistry Panel: Chemistry Panel: Yes No If yes, describe main abnormalities including values Other tests (describe) Previous Radiographs: Please make sure to attach any available images and reports available Previous Radiographs: Please make sure to attach any available images and reports available Yes No Date: Findings: Previous Ultrasounds: Previous Ultrasounds: Yes No Date: Findings: Other Imaging (CT/MRI): Current Medications: Current Medications: Yes No Medication / Dose / Duration Recent/Ongoing Treatments( Skin treatment, Chemotherapy, Rehab/physio): Prior Surgeries: Prior Surgeries: Yes No If yes, please specify (Procedure/Date) Anesthetic/Sedation History | Previous reactions to sedation/anesthesia: Anesthetic/Sedation History | Previous reactions to sedation/anesthesia: Yes No If yes, please describe Coagulopathy Risk| Known bleeding disorders or abnormal coagulation tests: Coagulopathy Risk| Known bleeding disorders or abnormal coagulation tests: Yes No If yes, please describe Infectious Diseases | Known/suspected infectious diseases: Infectious Diseases | Known/suspected infectious diseases: Yes No If yes, please describe Allergies | Known drug or material allergies: Allergies | Known drug or material allergies: Yes No If yes, please describe Behavioral Concerns | Handling precautions or aggressive behaviors: Behavioral Concerns | Handling precautions or aggressive behaviors: Yes No Additional relevant information Suspected Conditions/Differential Diagnoses: Specific Organs/Regions to Focus On: Procedures Requested: Procedures Requested: Diagnostic Ultrasound Fine Needle Aspirate(s) Tru-cut Biopsy(ies) (Requires discussion/approval by radiologist; typically requires general anesthesia) Cystocentesis Other Procedures: If aspiration or biopsy requested, recent PT/PTT test performed: If aspiration or biopsy requested, recent PT/PTT test performed: Yes No Samples/slides to be sent by: Samples/slides to be sent by: OAESH Family Vet Attachments (Please ensure the following are included) - Complete Medical History | Laboratory Results | Previous Imaging Studies | Other Relevant Documents UploadPatient file, blood results, other files...Accepted files : jpg, jpeg, jpe, gif, png, ico, js, tar, xcf, docm, xlam, numbers. Max. file size: 10 MB Contact Preferences (Please enter veterinarian name here) Hello For legal reasons, this form must be completed and signed by the referring veterinarian. Forms completed by support personnel (including veterinary technicians or administrative staff) will not be accepted and your referral request may be rejected. For legal reasons, this form must be completed and signed by the referring veterinarian. Forms completed by support personnel (including veterinary technicians or administrative staff) will not be accepted and your referral request may be rejected. Phone Email Fax If urgent, specify reason: (This does not promise an earlier slot) Urgency Level: Urgency Level: Routine Urgent Please type your name as your signature. 14 + 14 = Send