Referring Hospital/Clinic *

Referring DVM *

Hospital/Clinic Email *

Additional Email (Optional)

Patient Last Name *

Patient First Name *

Species *

• Canine
• Feline
• Other

Breed *

Age *

Sex *

• Spayed Female
• Neutered Male
• Intact Female
• Intact Male
• Unknown

Weight (in kgs) *

Date of Ultrasound MM/DD/YY *

Ultrasound Exam Ordered *Select from MenuComprehensive AbdomenComprehensive EchocardiogramComprehensive Abdomen and EchocardiogramChest (non-cardiac)PregnancyThyroid, Lump, Ocular, Testicular

Telemedicine Choice *Select from MenuCardiologist EchoCardiologist Echo, ECG and/or XraysDr. Roth Jones AbdomenDr. Roth Jones Single SystemDr. Roth Jones Abdomen and Single SystemDr. Roth Jones Ultrasound with Xrays (up to 6 images)Dr. Roth Jones Stat ReportDr. Crews Abdomen or Single SystemDr. Crews Abdomen or Single System with Xrays (up to 6 images)Dr. Crews Stat ReportRadTerra AbdomenRadTerra Pregnancy or Single SystemRadTerra Ultrasound with Xrays (1-6 dicom images)RadTerra Stat

Pertinent History *

Grade of Heart Murmur (if Echo ordered)Select from Menu1/62/63/64/65/66/6

Pertinent Lab and/or Xrays Results *

Current Treatment and Medications

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