Patient Form | Pet Imaging

REQUEST FORM

PLEASE CALL/TEXT OR EMAIL TO SET UP AN APPOINTMENT

PLEASE NOTE: a completed form does not confirm an appointment, you must contact Pet Imaging directly

Hospital Name / Clinic

Patient's First Name

Patient's Last Name

Owner's first name

Services Requested*

Please check ALL that apply. If this is a STAT read, please call immediately so that your request can be processed. Required

Overseeing Veterinarian

Species:

Breed:

Patient DOB:

Patient Weight:

Clinical Exam Findings:

Presentation, Physical Exam, etc. Bulleted text is appreciated.

Current Medications

Any medications patient is currently on, or has been administered in the last 24 hours.

ABNORMAL Labwork Values

Please list any abnormal lab work values. You can alternatively email them to: info@petimaging.ca. Full lab work along with the ultrasound provides the most detailed case read.

Radiographic Findings

You may send up to 3 CURRENT radiographs or a report that are of the same cavity that is being examined. These will supplement the ultrasound, if needed. Email radiographs to: info@petimaging.ca

Primary Question to Be Answered in This Exam

Do you have an appointment scheduled for this ultrasound already? If so, when? If you DO NOT have a scheduled appointment, PLEASE CONTACT PetImaging directly.*

Email for Submission Confirmation & Contact*

Thanks for submitting!