Abdominal Form
ABDOMINAL ULTRASOUND Has the patient had a previous ultrasound or echocardiogram with Paw Prints?
CLINIC DETAILS All fields marked with a red asterisk * are required
PATIENT DETAILS All fields marked with a red asterisk * are required
Species
Select One Canine Feline Other
APPOINTMENT DETAILS All fields marked with a red asterisk * are required
What type of Interpretation do you require?
Priority weekend report ($95)
X-rays to send to radiology with internal medicine case ($120 for first series, $60 for each additional)
Priority Report (x-rays only) ($60)
Priority weekend report (x-rays only) ($95)
X-rays with ultrasound ($60 for first series, $60 for each additional)
Please select the correct x-ray series
Please select the correct x-ray series
What studies are being requested today?
ORGANS OF INTEREST All fields marked with a red asterisk * are required
Was the patient sedated for this exam?
What is the organ of concern/reason for this study?
PATIENT HISTORY All fields marked with a red asterisk * are required
Please summarize the patient's history and clinical signs that prompted this ultrasound exam (max 500 chars)
Please include the duration of signs, severity, known triggers, etc.
PHYSICAL EXAM All fields marked with a red asterisk * are required
Please summarize the physical exam findings for this patient (max 500 chars)
If not performed, please type "not performed".
Which of the following best describes the patient's attitude/demeanor?
DIAGNOSTICS All fields marked with a red asterisk * are required
Completed diagnostics (max 500 chars)
Please summarize results of any other completed diagnostics. Write "none" if N/A.
Pending diagnostics (max 250 chars)
Please list any pending diagnostics. Leave blank if N/A.
Planned diagnostics (max 250 chars)
Please list any planned diagnostics not yet in progress or performed. Leave blank if N/A.
TREATMENT All fields marked with a red asterisk * are required
Do you have a treatment plan for the current clinical signs?
Please describe your current treatment plan (max 250 chars)
Please describe any prior treatments the patient received for the current clinical signs and effectiveness. (max 250 chars)
ADDITIONAL CONCERNS All fields marked with a red asterisk * are required
Are there any specific clinical questions or concerns you would like addressed in this report? (max 250 chars)
This information will help the specialist address your specific concerns for this patient.
Please list any differential diagnoses you would like us to comment on. (max 250 chars)
Is there any additional medically pertinent information to share
Please provide the medically pertinent information or case impressions (max 250 chars)
Do you have files to attach?
Maximum 10 files up to 10MB each.
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