Appointment Information Form

Hospital Name*
If multiple locations, please state which location
Patient First Name
Patient Last Name
ROUTINE OR STAT?*
IF STAT, PLEASE CALL IMMEDIATELY TO SCHEDULE. Based on Sonographer/Specialist availability.
Services Requested*
Please check ALL that apply. If this is a STAT read, please call immediately so that your request can be processed.
- STAT (CALL IMMEDIATELY TO SCHEDULE)
- Abdominal
- Thoracic (Non-Cardiogenic)
- Echo only – internist read
- Echo only – cardiologist read
- Comprehensive echo(this includes ECG)
- ECG only
- Thyroid
- Other
Overseeing Veterinarian
Species:
Breed:
Patient DOB:
Patient Gender:
- Male Intact
- Male Neutered
- Female Intact
- Female Spayed
- Unknown
Patient Weight:
Is this a staff member's pet?
Clinical Exam Findings:*
Presentation, Physical Exam, etc. Bulleted text is appreciated. Maxlength: 800
Current Medications
Any medications patient is currently on or that have been administered in the last 24 hours.
ABNORMAL Labwork Values
Please list any abnormal lab work values. Example: ALT 400, BUN 47. You can alternatively email them to: info@thefocalzone.com The specialists have recently requested full lab work along with the ultrasound to provide the most detailed case read. Maxlength: 800
Radiographic Findings
You may send up to 3 CURRENT radiographs that are of the same cavity that is being examined. These will supplement the ultrasound, however the main ddx will be made from the ultrasound itself. Please contact us if you have further questions. Email radiographs to: info@thefocalzone.com Maxlength: 800
Primary Question to Be Answered in This Exam
Please indicate the date and time of your patient's confirmed ultrasound appointment scheduled with our team.*
Email for Submission Confirmation & Contact*
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