Ultrasound Submission Form Question Title * 1. Patient's name Question Title * 2. Owner's name (last, first) Question Title * 3. Birth Date Question Title * 4. Species Canine Feline Question Title * 5. Gender Male Female Question Title * 6. Altered Yes No Question Title * 7. Breed Question Title * 8. Weight (kg) Question Title * 9. Appointment Date / Time Date Time AM/PM - AM PM Question Title * 10. Study type ABDOMINAL CERVICAL THORACIC (NON-CARDIAC) Question Title * 11. Requesting clinician's information Clinician's name Hospital name Hospital phone number Hospital email address Question Title * 12. Clinician's concerns Question Title * 13. Relevant recent patient history/reason for requesting ultrasound: (1-2 sentences) Question Title * 14. List relevant bloodwork/UA results (or email to emorrison@hnradiology.org) Question Title * 15. Describe radiograph abnormalities and email recent radiographs to emorrison@hnradiology.org Question Title * 16. Previously diagnosed patient conditions Question Title * 17. Patient's current medications Question Title * 18. I have performed bloodwork including at least a PCV/TS and platelet count in the last 30 days (required for FNA). I understand that an FNA will not be performed if platelet counts are inadequate YES NO Question Title * 19. I would like a fine needle aspirate (FNA) of any organs or masses of interest Question Title * 20. I have discussed with my client that their pet will be sedated for the ultrasound exam YES NO Question Title * 21. I believe that this patient is stable for an outpatient ultrasound exam YES NO Question Title * 22. I confirm that I have evaluated this patient in the last 30 days and believe that light sedation is appropriate (usually 0.2- 0.3 mg/kg butorphanol) Yes No Question Title * 23. Electronic signature Done