Company

This field is for validation purposes and should be left unchanged.

A copy of this form will be emailed to you upon completion, for your reference.

Referring Hospital(Required)

Name of referring veterinarian(Required)

First Last

Is the patient you're referring currently stable?(Required)

Yes

No

Unsure/Other

For urgent requests, please call (519) 649 0080 to arrange a transfer directly with the Diagnostic Imaging team. The remainder of this form can be completed when practicable based on the patient's condition.

Patient Details

Patient Name:(Required)

First Last

Patient Breed:(Required)

Patient age / birthdate (if known):

Sex:(Required)

Temperament(Required)

Weight in kg(Required)

Is this patient's Rabies vaccine up-to-date?(Required)

Yes

No

Unsure/Other

For echocardiograms only: Please provide vaccine due date (if known)

Please Specify

Reason for recheck:(Required)

Updated clinical information, diagnostics, etc.(Required)

Relevant physical exam findings:

Current medications:(Required)

Please note: Unless medically contraindicated, we request that you prescribe Pre-Visit Pharmaceuticals (for example, gabapentin/trazodone) for this patient to reduce fear, anxiety, and stress during their ultrasound appointment – regardless of temperament. Please include above.

Current diet (echocardiograms only):

Presenting Complaint and Medical History (please include previous diagnostic findings):(Required)

Please email any relevant supporting documents/PDFs directly to imaging@neighbourhoodpetclinic.com.

Reason for Ultrasound Evaluation and Clinical Questions:(Required)

Client Details

Client ID in your practice management software:

Client Name:(Required)

First Last

Client Phone Number:(Required)

Client Email:(Required)

Please add any pertinent details about the family or client availability here:

How did you hear about our ultrasound referral services?

Please specify:

Acknowledgements & Contact Details

DISCUSSION OF RESULTS (Required)

By clicking below, you acknowledge that you have notified your client that the results will be sent to you (the referring veterinarian) within 1-3 business days of their visit, and unless urgent and you are unable to be reached, results will not be discussed with your client at the time of the appointment.

Consent for Discussion of Results:(Required)

I have read, understand, and have notified my client of the above

PRESCRIPTION OF PRE-VISIT ORAL SEDATIVES (Required)

In line with Fear Free principles, we request that you prescribe pre-visit pharmaceuticals such as gabapentin and/or trazadone prior to all patients ultrasound appointments, regardless of temperament. By clicking below you acknowledge that you will prescribe these medications unless medically contraindicated.

Consent for Provision of Pre-visit Sedation:(Required)

I have read and understand

USE OF INJECTABLE SEDATION (Required)

In addition to gabapentin and/or trazodone, some patients will require injectable sedation to facilitate restraint and to allow proper acquisition of diagnostic images. If required, this will be provided under the delegation of a veterinarian on-site at the time of the appointment. We will quote for the cost of sedation and reversal once we contact your client. If sedation is not required, it will not be charged or administered.

Consent for the Use of Injectable Sedation:(Required)

I have read and understand

SECONDARY INTERVENTIONS (Required)

If the preliminary findings of this service warrant additional ultrasound-guided procedures (e.g., fine needle aspirates or fluid collection), assuming the patient is stable and other immediate interventions are not required, how would you like to proceed?

Consent for Secondary Interventions(Required)

I give permission for the Diagnostic Imaging team to obtain client consent for further procedures or diagnostic workup while the patient is under sedation, if it is in the best interest of the patient.

I request that the patient's sedation is reversed if I am not reachable. I will contact the family and arrange any next steps directly.

EMERGENCY INTERVENTIONS (Required)

In the event of an emergency, if you cannot be reached, please note that a veterinarian on-site may be requested to act on your behalf, if it is in the best interest of the patient.

Consent for Emergency Interventions:(Required)

I have read and understand.

What is the best phone number to reach you in case of an emergency or unexpected intervention with your patient? Include an extension if required.(Required)

What is the best email address to reach you at directly regarding this case? Please note that this email address is also where the radiology report will be sent, if applicable.(Required)

Diagnostic Imaging Referral Form