Date of Ultrasound Appointment (required - mm/dd/yyyy)
Clinic Name (required)
First Name (required)
Last Name (required)
Clinic Phone Number (required)
Clinic/Doctor Preferred Email for Results (required)
Clinic/Doctor Additional Email(s) for Results (optional)
Owner First Name (required)
Owner Last Name (required)
Patient ID (this is the ID you use when entering patient data into X-Ray machine) (required)
Patient Name (required)
Date of Birth (required)
Weight (required in lbs)
Sex (required) (please indicate altered status)
Is patient up to date on a rabies vaccine?
Is this a recheck from a previous 4 Paws Imaging ultrasound?
Pertinent History (Please include presenting clinical signs, even if normal)
Are there radiographs to submit for interpretation along with this ultrasound?
If you anticipate your patient needing fine needle aspirates, please obtain consent prior to scan, as well as permission to sedate if needed.
When you submit this form, you will be emailed a copy of the information you submitted. You can print that email for your records.
Please fill out, only if new to 4 Paws Imaging
Hospital Name (required)
Phone Number (required)
Your Email (required)
Best Contact for Invoicing & Billing
Contact Name (required)
Direct Phone Number (required)