Outpatient Abdominal Ultrasound Request Form Outpatient Ultrasound Request Form Specifics of your request such as questions about positioning and scan time can be directed to an AVIM&O staff member by calling 410-828-0911, opt. 2 (Hunt Valley) or 410-441-3304, opt. 2 (Columbia). We will do our best to accommodate your requests, but same-day scans may not be possible due to pre-existing case load. We will reach out to the client to schedule once we have received the request and all necessary medical records (last year of medical records, recent lab work and radiographs and any other pertinent information). This form should be submitted at least 24 hours in advance of the date that you are requesting. All imaging requests require recent physical examination (within two weeks of the scan) and veterinarian approval for sedation (with torbugesic, midazolam, or alfaxolone) on clinically stable patients. If a patient is deemed a triage level 2, clinically not stable, the emergency veterinarian & ultrasound technician will have the right to decline the outpatient ultrasound and recommend the patient be seen through the emergency department for further recommendations. Keep in mind sedation may not be needed, but veterinarian approval for all the options are required. Incomplete packages (i.e. no blood work or medical records) will not be reviewed until all information is provided. Examples: Patients needing abdominocentesis prior to scanning, minimally responsive, hemorrhage (HGE, hemoabdomen, etc.), GDV (bloat), febrile, etc. If your patient does not meet this criteria, you are welcome to contact our emergency department where they can assist you in further recommendations. They can be reached at (410) 252-8387 opt.1. Location * Select LocationColumbiaHunt Valley Type of Ultrasound Select ProcedureFocal Ultrasound (Limited exam focused on specified organ systems; includes written report from radiologist)Pregnancy Ultrasound ((Limited exam focused on confirming pregnancy; no written report)Abdominal Ultrasound Veterinarian consents to use of sedation (torbugesic, midazolam, or alfaxolone) as determined necessary by the ultrasound technician. * I consent What diseases/problems are you trying to identify/rule out? * This will aid the radiologist when reading the scan. Pertinent Patient History * Referral Veterinarian Information Name * Name First First Last Last Phone * Specialty (if applicable) Hospital Name * Hospital Address * Hospital Address Hospital Address Hospital Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Best Contact Number * Email * Radiology report will be emailed within 1 business day. Referred Client & Patient Information Pet's Name * Owner's Name * Owner's Name First First Last Last Owner's Phone * Secondary Phone Owner's Email * Owner's Address * Owner's Address Owner's Address Owner's Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Species * Canine Feline OtherOther Sex * Male Female Male - Neutered Female - Spayed Breed * Weight * Age * Is this patient a CAUTION/AGGRESSIVE? * Yes No Current Medications * Has the patient had any prior complications with general anesthesia? * Does the patient have any allergies to medications? * Upload copies of the patients’ medical records * Drop a file here or click to upload Choose File Maximum file size: 52.43MB Please upload all medical records & files. If you experience trouble when uploading records and/or submitting the form, please email records for Hunt Valley to AVIM.HuntValley@nva.com and records for Columbia to AVIMO.Columbia@nva.com. I grant AVIM&O, its representatives and employees the right to take photographs of my pet and me. I authorize AVIM&O, its assigns and transferees to copyright, use and publish the same in print and/or electronically. * Yes No Captcha Submit If you are human, leave this field blank.
