Exam request form - mobile veterinary services

Hospital Name

If multiple locations, please state which location

Patient's First Name

Patient's 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
Echocardiogram
Thoracic (WITH Echo)
Double Cavity (Abdominal Plus An Additional Cavity)
Other
ECG with Cardiologist Interpretation

Overseeing Veterinarian

Species:

Breed:

Patient DOB:

Patient Gender:

Patient Weight:

Is this a staff member's pet?

Clinical Exam Findings:

Presentation, Physical Exam, etc. Bulleted text is appreciated.

Current Medications

Any medications patient is currently on, or has 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.

For ECHO Only: Blood Pressure*

This is requested by the interpreting cardiologist.

HR/RR/BP:*

This is requested by the interpreting cardiologist.

Is there a Heart Murmur? If so, please grade.*

This is requested by the interpreting cardiologist.

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 me if you have further questions. Email radiographs to: info@thefocalzone.com

Primary Question to Be Answered in This Exam

Do you have an appointment scheduled for this ultrasound already? If so, when? If you DO NOT have a scheduled appointment, PLEASE CONTACT The Focal Zone directly.*

Email for Submission Confirmation & Contact*

Submit Request Form

Please CALL/TEXT or email to set up an appointment

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