0399 0400 - Atlantic Veterinary Internal Medicine & Oncology (AVIM&O) - Outpatient Abdominal Ultrasound Request Form

Outpatient ultrasounds are offered exclusively at our Hunt Valley location. Forms to be sent to Hunt Valley.
Type of Ultrasound
Veterinarian consents to use of sedation (torbugesic, midazolam, or alfaxolone) as determined necessary by the ultrasound technician.*

I consent
What disease/problems are you trying to rule out?*
This will aid radiologist when reading the scan.
Has the patient had any prior complications with general anesthesia or sedation?

YesNo
The referring veterinarian is responsible for going over the ultrasound report with the pet owner.
Pertinent Patient History*
Referral Veterinarian Information
Name*

First NameLast Name
Email*
Radiology report will be emailed within 1 business day
Phone Number*
Please enter a valid phone number.
Specialty (if applicable)
Hospital Name*
Hospital Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best Contact Number*
Please enter a valid phone number.
Referred Client Information
Owner's Name*

First NameLast Name
Owner's Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Owner's Email*
example@example.com
Owner's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pet's Information
Pet's Name*
Pet Sex*
Pet Age*
Pet Breed*
Pet Weight*
Pet Species*

CanineFelineOther
Is this patient a CAUTION/AGGRESSIVE*

YesNo
Current Medications*
Does the patient have any allergies to medications?*
File Upload*

Cancelof
Please upload all medical records & files. If you experience trouble when uploading records and/or submitting the form, please email records for Hunt Valley to AVIM.HuntValley@nva.com .
I grant AVIM&O, its representatives and employees the right to take photographs of my pet and me. I authorize AVIM&O, its assigns and transferees to copyright, use, and publish the same in print and/or electronically.*

YesNo
Are You A Robot?*
Should be Empty:

Referral Veterinarian Information

Referred Client Information

Pet's Information