Submit your Appointment Information

After scheduling your appointment, please fill out this form.

Appointment Information Form

PRIOR to submitting this form, please CALL or EMAIL to schedule your patient's ultrasound appointment with The Focal Zone team at: 1-289-808-2608 or at: info@thefocalzone.com

  • The Focal Zone requires a completed online patient form PRIOR to the start of any sonographic services.

    Please note: ALL sections are required. For any question that does not apply to your patient, please write N/A.
  • If multiple locations, please state which location
  • IF STAT, PLEASE CALL IMMEDIATELY TO SCHEDULE. Based on Sonographer/Specialist availability.
  • Please check ALL that apply. If this is a STAT read, please call immediately so that your request can be processed.
  • Presentation, Physical Exam, etc. Bulleted text is appreciated. Maxlength: 800
  • Any medications patient is currently on or that have been administered in the last 24 hours.
  • Please list any abnormal lab work values. Example: ALT 400, BUN 47.
  • You may send up to 3 CURRENT radiographs that are of the same cavity being examined. These supplement the ultrasound; however, the main DDX will be made from the ultrasound itself. Please contact us if you have further questions. Email radiographs labeled with the patient's full name and your clinic's name to info@thefocalzone.com. Max length: 800