Ultrasound Only Referral Form

All non-urgent and stable patients being referred for just ultrasounds must have this form submitted by the referring veterinarian prior to being seen for an ultrasound.

Ultrasound Only Referral Form

Veterinarian Information
Referral Date*
MM slash DD slash YYYY
Referring Hospital*
Referring Veterinarian*
Phone*
Fax Number*
Email Address*
Veterinarian Address
Street Address Address Line 2 City State ZIP Code
Owner Information
Owner's Name*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Patient Information
Patient Name*
Breed*
Color*
Weight*
Species*
Spayed / Neutered*
Sex*
Mandatory Client Awareness
Client has been made aware of approximate costs:*
Abdominal ultrasound: $708.98
Radiology Consult: $194
Sedation if necessary for patient/staff safety: $50-$100
- Yes
Client is aware they will not be speaking to a veterinarian or internal medicine specialist at AERA and that you, their primary veterinarian will be responsible for reviewing the ultrasound findings and discussing next steps.*
- Yes
Client is aware that the patient needs to be fasted for 12 hours (water is OK)*
- Yes
Medical Information
Pertinent History/pre-existing conditions:*
Current Medications:*
Will this patient benefit from sedation for the purpose of this ultrasound?*
- Yes
- No
Previous anesthetic complications:*
Physical exam concern:*
Precious Diagnostics Performed:*
Drop files here or

Max. file size: 300 MB.
Kindly submit ALL doctors notes, lab results radiographs and other image reports with this referral form.
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Ultrasound Only Referral Form

Ultrasound Only Referral Form

Veterinarian Information

Owner Information

Patient Information

Mandatory Client Awareness

Medical Information