Referral Form

Radiology Outpatient Ultrasound Service

*Dr Rajdeep Multani, DVM, DACVR

    Hello

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    Recent CBC:

    Chemistry Panel:

    Previous Radiographs: Please make sure to attach any available images and reports available

    Previous Ultrasounds:

    Current Medications:

    Prior Surgeries:

    Anesthetic/Sedation History | Previous reactions to sedation/anesthesia:

    Coagulopathy Risk| Known bleeding disorders or abnormal coagulation tests:

    Infectious Diseases | Known/suspected infectious diseases:

    Allergies | Known drug or material allergies:

    Behavioral Concerns | Handling precautions or aggressive behaviors:

    Procedures Requested:

    If aspiration or biopsy requested, recent PT/PTT test performed:

    Samples/slides to be sent by:

    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

    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.

    Urgency Level:

    14 + 14 =