Ultrasound Referral Form

Referral Information

Referring Dr. *

Referring Veterinarian Hospital *

Email *

Phone *

Fax Number for Report *

Patient Information

Client (Owner) First Name *

Client (Owner) Last Name *

Client (Owner) Address *

Client (Owner) Phone *

Client (Owner) Email

Patient Name *

Species *

Breed *

Sex *

Reproductive Status *

Patient Date of Birth *

Medical Details

Clinical History (primary reason for imaging, physical exam findings, recent lab work [within 30 days] pertinent medical history, etc.) *

Does this patient have any medical reason to not sedate and/or perform fine needle aspirates if indicated? *

Yes

If yes, please explain why.

Should a mass or lesion be found, and we are granted client consent, would you like us to obtain a FNA? *

Yes

Does your patient have any drug allergies and if so please explain? *

I am referring this patient for *

Abdominal ultrasound

Echocardiography

Thoracic ultrasound / other

w/ FNA

Spam Blocker

Ultrasound Protocol

Stoney Creek Veterinary Hospital is excited to announce that our hospital will be accepting referrals for outpatient ultrasound services from our Veterinary Colleagues in the Delaware County region!

Ultrasounds will be performed and interpreted by our board-certified Medical Director, Dr Tam Mengine, DVM, DABVP (canine/feline practice), and then sent for a telemedicine review by a board-certified specialist. Dr. Mengine first received training in ultrasound during a small animal internship at Texas A&M University, and has subsequently gained many years of experience performing abdominal ultrasounds and limited echocardiograms as both an emergency clinician and a general practitioner. Dr. Mengine is a member of the International Veterinary Ultrasound Society and is currently pursuing their rigorous certification program in Veterinary Sonography.

If you have a pet who needs an abdominal ultrasound please give our office a call to set up this appointment. We will need a referral from your current veterinarian and all recent medical records including lab work.

Ultrasound Referral Form

Referral Information

Patient Information

Medical Details

Ultrasound Protocol

New Patients Welcome