Ultrasound Referral Form

When referring your patient to our hospital, please complete this form along with all pertinent medical records. If you have any questions while completing this form, please reach out to us at 204-452-0911 or send an email to info@bridgwatervethospital.ca.

REFERRING HOSPITAL INFORMATION

Tentative Diagnosis *

Brief Medical History *

Current Medications and Supplements *

Do we have authorization to use sedation, if needed? *

Yes
No

Lab Findings:

Radiographic Findings:

Please Upload the Patient's Medical Records

What questions would you like answered?

If a mass is found, do you request for an FNA to be preformed? *

Yes
No

Please check the box to confirm your client has been informed that it will take 24 - 48 hours for results to be forwarded to referring hospital. Bridgwater will not be reviewing FNA results with the client. They will be forwarded to the referring veterinarian *

Bridgwater Veterinary Hospital and Wellness Centre will not discuss ultrasound results with the client. In the event a patient is unstable to wait until referring hospital is open – we will use our discretion to discuss results.

If you would like the patient transferred to the care of Bridgwater Veterinary Hospital and Wellness Centre, please indicate so below.

I would like to transfer this patient's care to Bridgewater Veterinary Hospital and Wellness Centre.

ALL ULTRASOUND PATIENTS MUST BE FASTING – SHOULD THIS BE A CONCERN, PLEASE CALL OUR HOSPITAL TO DISCUSS WITH A VETERINARIAN.

Ultrasound Referral Form

REFERRING HOSPITAL INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

PATIENT HISTORY

Ultrasound Referral Form

REFERRING HOSPITAL INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

PATIENT HISTORY

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