4 Paws Imaging Centers - Patient History (Abdominal)

Clinic Name(Required)

Date of Ultrasound Appointment(Required)

MM slash DD slash YYYY

Phone(Required)

Referring Doctor

Name Of Referring Doctor(Required)

First Last

I allow the 4 Paws Imaging Centers to contact me through text messages.

Yes

Clinic/Doctor Preferred Email for Results(Required)

Clinic/Doctor Additional Email(s) for Results (Optional)

I understand that 4 Paws Imaging Centers will not be relaying results of this diagnostic to owner. They will perform the diagnostic, and return results to referring DVM to relay results to owner.(Required)

I Understand

Owner's name(Required)

First Last

Patient ID (this is the ID you use when entering patient data into X-Ray machine)(Required)

Patient Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Weight (required in lbs)(Required)

Species(Required)

Sex (please indicate altered status)(Required)

Breed(Required)

If your patient is not updated on a rabies vaccine, please call 4 Paws Imaging at 630-746-1382 to discuss protocol

Is patient up to date on a rabies vaccine?(Required)

Yes

Is this a recheck from a previous 4 Paws Imaging ultrasound?(Required)

Yes

Pertinent History (Please include presenting clinical signs, even if normal)(Required)

Current Medications(Required)

*Please indicate the start date of all cardiac medications.

Differentials(Required)

Are there radiographs to submit for interpretation along with this ultrasound?(Required)

Yes

If you are submitting radiographs with your abdominal ultrasound please indicate below the body cavity you would like to be interpreted.(Required)

Abdominal Cavity

Thoracic Cavity

Both

Date radiographs were taken:(Required)

MM slash DD slash YYYY

6 radiographs max
Additional fee applies
Must be sent in dicom format to our server
Radiographs older than 2 weeks will not be accepted

If you anticipate your patient needing fine needle aspirates, please obtain consent prior to scan, as well as permission to sedate if needed.(Mobile only)

When you submit this form, you will be emailed a copy of the information you submitted. You can print that email for your records.