Outpatient Ultrasound Request - Four Seasons Veterinary Specialists

Outpatient ultrasounds are available Monday through Friday, by appointment only.

Please complete this form, and email it to us with the pertinent patient record, radiographs, labwork and any previous ultrasound reports to [email protected]

Date of appointment

Time of appointment

:

Referring clinician available to speak during/after the ultrasound, if needed?*

Yes
No

Referring Veterinarian Phone

Referring Practice*

Referring DVM*

Pet Owner's Name*

Owner’s best contact number

Patient name*

Dog or Cat*

Dog
Cat

Breed*

Age*

Sex*

M
MN
FS
F

Outpatient ultrasounds are diagnostic tests ordered by the family veterinarian and performed by the Radiology department. You will receive the ultrasound report the same day. If you feel a consult is needed, or wish to refer the patient to another Four Seasons department (e.g. Internal Medicine, Surgery, Oncology), please call Four Seasons at 970 800-1106.

Stable patients only: Patients need to be clinically stable for outpatient ultrasounds. Please refer less stable patients to our ER department for diagnostics and support.

Type of Outpatient Ultrasound requested

Abdomen
Thorax (without FNA)

Please note: Intrathoracic fine needle aspirates, musculoskeletal and neck ultrasound exams aren’t performed as outpatient appointments due to the frequent need for injectable sedation. Please schedule these patients through the Emergency or another Four Seasons department, by calling 970 800-1106.

Sedation: Is it likely that this patient will need sedation?* Please consider prescribing an oral sedative for your anxious/fearful or large patients prior to the ultrasound appointment. This can greatly improve our ability to perform a better examination, with less stress. If an injectable sedative is required, this is facilitated through our ER department and there will be additional costs to the client.*

Yes
No

Fine needle aspirates: To perform FNA’s safely, we require a CBC showing adequate platelets for clotting, performed within the last 2 weeks. Has a CBC been performed within the past 2 weeks of the ultrasound appointment?

Yes
No

If so, are platelets within safe range?

Yes
No

Veterinarian's Summary: Please share pertinent information about the patient’s history, your findings, and lab and/or diagnostic imaging results, to help us know why we are performing the ultrasound:*

Patient records: You may attach pertinent patient records, radiographs, lab work and any previous ultrasound reports here, or send separately.

Drop files here or

Accepted file types: doc, docx, pdf, gif, jpg, jpeg, png, Max. file size: 50 MB.

We look forward to seeing your patient. Please contact us if we may be of any further help: 970 800-1106

Phone

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