All non-urgent and stable 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.

Outpatient Ultrasound Hours*

*Except holidays. Please call to verify availability before coming in.

• Referring Veterinarian's Information

• First Name*
• Last Name*
• Clinic*
• Email*
• Would you like to receive VSC's Referring Veterinarian Newsletter?
  • Yes, please.
  • No, thank you.
• Personal Email*

• Client's Information

• First Name*
• Last Name*
• Client's Mobile Phone*
  The client will automatically receive a one-time SMS text message that we have received your ultrasound referral and asks them to check the provided email for detailed instructions. The client can reply STOP at any time to opt out.
• Client's Email*
  The client will automatically receive an email that we have received your ultrasound referral along with detailed instructions.
  Enter Email Confirm Email

• Patient's Information

• Patient's Name*
• Species*
  • Canine
  • Feline
• Weight (kg)
• Breed*
• Age*
• Sex*
  Spayed FemaleFemaleNeutered MaleMale

• Mandatory Client Awareness

  Client must be made aware of every topic prior to being referred to VSC for a non-urgent ultrasound.
• 1. Client has been informed of $755 ultrasound fee (one body cavity).*
  If additional diagnostics such as fine-needle aspiration are necessary and able to be performed, 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.
• 7. Client is aware that this referral is only good for the next 30 days.*
  Yes, client has been made aware.

• Medical Information

  Any size files can also be uploaded below.
  
  Records can also be sent separately to help@vetspecialty.com.
• Body cavity to ultrasound*
  Please note that selecting more than one cavity to ultrasound will incur additional fees.
  • Abdomen
  • Chest
  • Neck
• 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.
  
  Clicking on "select a folder", will only allow the upload of an entire folder and not individual files.
  Add your files

  Or select a folder

  Maximum size: 1 GB

  • Files
  • Folders

  Download

  Start Upload

• IF CLICKING SUBMIT BUTTON BELOW DOES NOT DISPLAY SUBMISSION SUCCESSFUL, PLEASE SCROLL UP, CORRECT ANY FIELDS HIGHLIGHTED IN RED, AND TRY AGAIN.

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

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