Ultrasound-only Referrals EFFECTIVE MAY 10th, 2021: All non-urgent patients being referred for just ultrasounds must have this completed form submitted by the referring veterinarian before they are able to be seen by our Imaging Department. This form should be completed by a veterinarian. Referring Veterinarian's InformationFirst Name* Last Name* Clinic* Email* Would you like to receive VSC's Referring Veterinarian Newsletter? Yes, please. No, thank you. Personal Email* Client's InformationFirst Name* Last Name* Phone*Client's Email*The client will automatically receive an email that we have received your ultrasound referral along with detailed instructions. Patient's InformationPatient's Name* Species* Canine Feline Weight (kg) Breed* Age* Sex*Spayed FemaleFemaleNeutered MaleMaleMandatory Client AwarenessClient must be made aware of every topic prior to being referred to VSC for a non-urgent ultrasound.1. Client has been informed of $688 ultrasound fee.*If additional diagnostics such as fine-needle aspiration or core biopsy are necessary, the Imaging Department will provide an appropriate estimate to the client and will only proceed with their consent. Yes, client has been made aware.2. This patient will only be seen by our imaging department and the client will not be speaking with a VSC doctor unless the ultrasound findings reveal something urgent.* Yes, client has been made aware.3. Non-urgent ultrasounds are performed on a first-come, first-served basis and the client may have to wait several hours or asked to return on a future date.* Yes, client has been made aware.4. This patient needs to have been fasted for 12 hours prior to the non-urgent ultrasound.* Yes, client has been made aware.5. Client is aware that you, their primary veterinarian, will be responsible for reviewing the ultrasound findings and discussing the next steps.* Yes, client has been made aware.6. Patient may need to be sedated for safety and/or diagnostic accuracy reasons, but there will not be any additional fees for sedation. Yes, client has been made aware.Medical InformationAny size files can also be uploaded below. Records can also be sent separately to help@vetspecialty.com. Reason for Non-urgent Ultrasound*Primary Problem(s)*Pertinent Medical History*Diagnostic Tests Performed/Results*Type NONE if applicable.Current Medication*Type NONE if applicable.Previous surgical and/or other procedure(s) and date(s)Upload Any Size Files (records, labs, radiographs, ultrasounds, MRIs, CTs, etc.)Please upload a one-year history, current blood work, imaging, and any other relevant information.To view this content, you need to have JavaScript enabled in your browser.To do so, please follow these instructions. Add your files Or select a folder Maximum size: 488 GB Files Folders IF CLICKING SUBMIT BUTTON BELOW DOES NOT DISPLAY SUBMISSION SUCCESSFUL, PLEASE SCROLL UP, CORRECT ANY FIELDS HIGHLIGHTED IN RED, AND TRY AGAIN.
