Case Submission Form - Pet Ultrasound Partners

Case Submission Form (NEW)

Name of Clinic

Ordering Veterinarian

Owner's Name

Phone

Name of Pet

Age

Years

Months

Species

Breed

Gender

Pet Weight

Weight Unit

Current Medications

Requested Testing

Reason for Exam

Pertinent History (Summary)

Please provide the most recent physical exam information and TPR, including any abnormal diagnostic test results (lab work, radiographs, U/A, etc.).

Are there radiographs for submission?

Yes

Please attach abdominal radiographs here (JPEG format preferred):
If radiographs are not available in JPEG format, please send a DICOM viewer link, as you normally would when sending radiographs, to our email address at: [email protected]

Choose File

Radiographs sent to email

Does pet have a current heartworm test?

Yes

Result:

Positive

Negative

In cardiac cases with suspected diet related concerns, please provide current diet and duration. (optional)

Are there thoracic radiographs for submission?

Yes

Please attach thoracic radiographs here (JPEG format preferred):
If radiographs are not available in JPEG format, please send a DICOM viewer link, as you normally would when sending radiographs, to our email address at: [email protected]

Choose File

Radiographs sent to email

Please attach complete medical records/lab work/imaging results from the past year.
If you are unable to attach electronic records, please provide copies of written medical records on the day of the ultrasound exam.

I will upload electronic records

Copies of medical records will be available on day of scheduled scan

Upload medical records/lab work/imaging results

Choose File

Any specific case questions or concerns for cardiologist?

Do you have any specific case concerns/questions for the reading specialist?
Please note: reading specialist will be available for follow-up questions after finalized report

Do you have any specific case concerns/questions for the reading internist?
Please note: reading internist will be available for follow-up questions after finalized report

What email address would you like the report to go to: