Practice details Veterinary surgeon Practice Town Postcode Phone number Email address Owner details Title - None -MrMrsMissMs First name Surname Address Street Town County Postcode Phone number 1 Phone number 2 Email address Patient details Pet name Breed Species DOB Sex Male Neutered Male Entire Female Spayed Female Entire Outpatient details: Ultrasound / Echocardiography Clinical history Brief relevant clinical history, including presenting signs and provisional diagnosis: Questions Questions to be answered by the report: Areas to be scanned: Heart Abdomen Scan date Routine * Recent blood test results (haematology and biochemistry) MUST be included if contrast is required.* Outpatient Fees Outpatient echocardiogram - £500 Outpatient abdominal ultrasound - £575 Confirmation 1 I confirm that the patient is compliant with the statements below. If not, please detail above. - Does not have any metal fragments in any body part - Has not had any surgical intervention involving placement of metal implants, plates, or clips - Does not have any type of electronic, mechanical, or magnetic implant (excluding microchip) - Has not had any surgery in the past two months - Is not pregnant Confirmation 2 I confirm that I am a qualified veterinary surgeon, who has obtained consent from the patient’s owner to act on behalf of the patient above. The client has given permission for the administration of an anaesthetic to the above animal at Optivet Referrals, together with any other procedures which may prove necessary. The client understands that in the unlikely event of an emergency or where additional pain relief or sedation may be required, we will act in the best interest of the patient. The client has agreed that they understood that medicines may be used which are not licensed for use in dogs and cats. Confirmation 3 In the event that I cannot be contacted on the above number, I understand that Optivet Referrals will act in the best interest of the patient. Patient history / Recent blood testsPlease attach patient history and recent blood tests (we need both). Choose a file and then upload it. Repeat process for each file. Add a new file Upload Files must be less than 8 MB.Allowed file types: gif jpg jpeg png txt pdf doc docx. CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit
