Outpatient Ultrasound Request

Please fill out this form to request an appointment with our internal medicine specialist Kimberly Hammer, VMD, DACVIM (SAIM).

    All fields are required.
    This is a request for:

    RDVM Phone Number:

    RDVM Email Address:

    Hospital Name:

    Name of Referring Veterinarian:

    Service Requested (Absecon Veterinary Hospital Only):

    Patient Name:

    Client First Name:

    Client Last Name:

    Client Email Address:

    Client Phone Number:

    Patient Identifier (ID# used for the patient at your practice):

    Signalment (Patient's age, breed, sex):

    Reason for Ultrasound/Consult:

    Current Medication List

    Medication 1

    Name of Drug:

    Route:

    Dose in mg/kg:

    Frequency:

    Medication 2

    Name of Drug:

    Route:

    Dose in mg/kg:

    Frequency:

    Medication 3

    Name of Drug:

    Route:

    Dose in mg/kg:

    Frequency:

    Medication 4

    Name of Drug:

    Route:

    Dose in mg/kg:

    Frequency:

    Pre-Visit Medications & Sedation

    Unless medically contraindicated, patients should receive trazodone and/or gabapentin prior to their visit to facilitate patient relaxation and improved quality of study. Please dispense these oral medications from your practice. If we have not seen the patient at our hospital within the last year, we will not be able to dispense pre-visit medications prior to the scheduled ultrasound.

    Permission for Sedation?:

    Sedation Protocol

    Sedation Medication 1

    Name of Drug:

    Route:

    Dose in mg:

    Sedation Medication 2

    Name of Drug:

    Route:

    Dose in mg:

    Sedation Medication 3

    Name of Drug:

    Route:

    Dose in mg:

    Sedation Medication 4

    Name of Drug:

    Route:

    Dose in mg:

    Permission for Aspirates of Organs/Effusions?:

    Do you need a sterile urine sample? Please approve this with the client:

    Please upload any appropriate records for client:

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