Online form submission

Patient History Form – Echocardiogram

Date of Ultrasound Appointment (required - mm/dd/yyyy)

Clinic Name (required)

Referring Doctor
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)

Species (required)

Sex (required) (Please indicate patient's altered status)

Breed (required)

Is patient up to date on a rabies vaccine?
YesNo

Please note patient must be updated on a rabies vaccine per our policy.

Is this a recheck from a previous 4 Paws Imaging ultrasound?
YesNo

Murmur Grade?

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

Current Medications

Differentials

EKG study to be performed at time of echocardiogram (please note an additional fee applies)
YesNo

Are there radiographs to submit for interpretation along with this ultrasound?
YesNo

Date radiographs were taken:

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.

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