Outpatient Ultrasound Referral Form Please complete the form below so our team at Veterinary Medical Center of CNY can coordinate your patient’s outpatient ultrasound appointment efficiently and keep the process moving smoothly. Contact us at (315) 446-7933 if you have any questions. Outpatient Ultrasound Referral The Veterinary Medical Center of Central New York accepts clients on emergency and referral basis only. No routine veterinary care will be provided unless specifically authorized by the referring hospital. Referring Hospital * Phone * Referring Veterinarian * Practice Email * Owner Name * Owner Name First First Last Last Email * Phone * Pet Name * Age/DOB Weight Species * Breed Sex * - Please Select -MFM/CF/S List last vaccinations given and dates Current Medications (Dose, Route, Response) Chief Complaint * Duration of clinical signs: * Sedation: If your pet requires injectable sedation (aggressive patients, anxious patients, or patients >80 lb) a pre-sedation exam of $184 and the cost of sedation will be charged to the pet owner in addition to the ultrasound. The use of pre-sedation - as medically indicated - may reduce or eliminate the need for injectable sedation. * This patient will need injectable sedation. I will prescribe my patient oral sedation. This patient should not need any sedation. History, PE, and Clinical Findings Please attach any blood work or radiographs. Drop a file here or click to upload Choose File Maximum file size: 52.43MB Thank you for this referral and your ongoing support! Please feel free to contact us at any time. Captcha Submit If you are human, leave this field blank.
