Abdominal Ultrasound Referral Form

Any information that is not on the referral document will not be sent to the radiologist and therefore a less complete study will result.

 

Dr. Litchfield will not be going over results with clients.

 

Which practice would you like to register with?

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REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

Summary of bloodwork results, history, clinical signs, physical exam. The more detailed the information the better the study.

ie: hepatitis, hepatic neoplasia, biliary obstruction, pancreatitis

Patient Temperament

INFORMATION FOR REFERRING VETERINARIANS

Sedation Protocols

 

Light sedation such as butorphanol is often administered to keep patients calm and to provide pain relief during ultrasounds. Each patient will be assessed for their individual needs at the time of study. Fractious or highly stressed patients may receive further sedation to accommodate scanning and limit stress. Cardiac safe protocols are used such as midazolam/alfaxan for echos, only if patient requires. If you are declining sedation options as deemed necessary at the time of study, the study may not go forward or limited images may be taken.

Please advise if there are any contraindications to known sedation or previous reactions:

Please advise client to give any oral anti-anxiety meds as directed prior to their visit.

 

Abdominal Ultrasounds: Patients must be fasted for 8 -12 hours prior to study, unless otherwise directed.

 

Routine ultrasounds results: Expect up to 2-4 days for return of study. Updates will be provided if backlogs are expected.

STAT ULTRASOUND (Same day response. Referring DVM will provide results to client. Fee of $132 applies.)

Please advise client of fees and turnaround times prior to booking.

 

DR. LITCHFIELD WILL NOT BE TAKING OVER ANY PATIENT CARE FOR ULTRASOUND REFERRAL PATIENTS. ALL RESULTS WILL BE FORWARDED TO THE REFERRING DVM. IF OWNER IS PAYING FOR A STAT ULTRASOUND, A PLAN SHOULD BE IN PLACE FOR REFFERRING DVM TO GO OVER RESULTS. CONSIDER IF YOU EXPECT RESULTS AFTER THE CLOSE OF CLINIC OR IF REFFERING DVM IS NOT ACCESSIBLE ON THE DAY OF STUDY.

 

A cancellation fee of $50 will be billed to clients who do not provide notice within 24 hours.

I would like the results sent to me via

DOCUMENTS


i.e. bloodwork, medical history, etc.

Thank you for entrusting us with the care of your patient. We are happy to answer any questions you may have. A member of our team will reach out to you as soon as possible.

 

 

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