Southeast Alabama Veterinary Hospital

540 Westgate Parkway
Dothan, AL 36303


Ultrasound Referral Form

Referring Veterinarian (required)

Referral Veterinarian Email (required)

Referral Veterinarian Phone Number (required)

Client Name (required)

Client Phone Number (required)

Which Study (required)
Abdominal Ultrasound
Patient Name (required)

Species (required)
Patient Weight (required)

Patient Age (required)

History and Reason for Referral (required)

Most recent heartworm test and result (required)

Current medications including heartworm and flea prevention as well as any supplements (required)

IF ECHO is requested: Current CARDIAC MEDCATIONS names and dosages and response to treatment (required)

IF ECHO is requested: Have chest radiographs been taken? (required)
Please forward history, current lab work, and radiographs to RADIOGRAPHS MUST BE DICOM FILES

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