Survey - Angell Diagnostic Imaging Referral Form

This form is for Outpatient Abdominal Ultrasounds at Angell West in Waltham and does not include Internal Medicine consults. Please submit an Internal Medicine referral form if you wish to schedule a consult.

REFERRING VETERINARIAN INFORMATION

1.

Please provide your information.

*

Name:

Title	First Required	Last Required

*

Email: Required

*2.

Question - Required - Referring Veterinarian/Clinic:

(Maximum response 255 chars, approx. 5 rows of text)

*3.

Question - Required - Referring Veterinarian/Clinic Phone:

4.

Question - Not Required - Referring Veterinarian/Clinic Fax:

*5.

Question - Required - Report delivery via (please select one):

REFERRAL INFORMATION

Please note that your abdominal ultrasound appointment will be scheduled at Angell West in Waltham. Outpatient ultrasound is currently unavailable in Boston.

*6.

Question - Required - Would you like us to call your client to schedule an appointment?

CLIENT INFORMATION

*7.

Question - Required - Client's Name:

*8.

Question - Required - Client Address

(Maximum response 255 chars, approx. 5 rows of text)

*9.

Question - Required - Client email address

*10.

Question - Required - Client Phone Number:

PATIENT INFORMATION

*11.

Question - Required - Pet's Name:

12.

Question - Not Required - Species/Breed:

13.

Question - Not Required - Age:

14.

Question - Not Required - Sex:

15.

Question - Not Required - Has this pet been seen at AAMC before?

16.

Question - Not Required - Weight:

MEDICAL HISTORY

*17.

Question - Required - Presenting complaint:

(Maximum response 255 chars, approx. 5 rows of text)

*18.

Question - Required - Differential Diagnosis:

(Maximum response 255 chars, approx. 5 rows of text)

19.

Question - Not Required - Pertinent Medical History:

(Maximum response 255 chars, approx. 5 rows of text)

20.

Question - Not Required - Recent Vaccine History:

(Maximum response 255 chars, approx. 5 rows of text)

21.

Question - Not Required - Current Treatment:

(Maximum response 255 chars, approx. 5 rows of text)

22.

Question - Not Required - Current Medications:

(Maximum response 255 chars, approx. 5 rows of text)

23.

Question - Not Required - Additional Comments:

24.

Question - Not Required - Were radiographs taken?

25.

Question - Not Required - Were radiographs sent? Please email diagnosticimaging@angell.org and identify client/pet name and that the case is being referred for an RDVM ultrasound in the email.

26.

Question - Not Required - Was lab work done?

27.

Question - Not Required - Were lab results sent? Please email diagnosticimaging@angell.org and identify client/pet name and that the case is being referred for an RDVM ultrasound in the email.

28.

Question - Not Required - Abnormal diagnostic results at your clinic:

Guidelines for referral:

1. Non-critical patients only; those in need of urgent medical, surgical, or emergency care should be referred to one of those services directly.

2. This service does not offer fine needle aspirates or sedation. If either sedation or aspirates are indicated for this exam, the client should make an appoinment with our Internal Medicine service at 617-541-5186 (Boston or Waltham locations).

3. Once you have filled out all required fields and hit submit on this form, we will contact your client to make an appointment. If the client prefers to call us at their convenience, please indicate this on the form. If you prefer, you may make the appointment for your client by calling: 781-902-8400 ext. 4009.

4. Please clarify with your client that an Internal Medicine consult with the client is not part of the outpatient ultrasound service. A separate appointment must be made for a consult.

5. Please encourage the client to read the Client Information Handout.

Procedure details: Please discuss the following points with your client prior to their arrival:

1. Patient should be fasted to allow for optimal evaluation of the cranial abdomen.

2. The pet's abdomen will be shaved and a complete ultrasound performed.

3. The client should be instructed to discourage their pet from urinating before the examination as a full bladder can be beneficial when imaging.

4. Should the ultrasound exam results warrant urgent intervention, at your discretion and in consultation with the client, you should prepare the client for possible admission to the hospital via the emergency service. We will facilitate this process when necessary. Additional fees will be incurred.

5. Our doctor will communicate findings to your office via fax, email or rvetlink. You may share the report with the client at that time.

6. Clients will be encouraged to direct follow up questions to you, their primary care doctor of record. The doctor does not typically speak to the client at the completion of the study.

*29.

Question - Required - (Please check off the circle)

I acknowledge that I have read and understand the above referral guidelines and procedure details.

For further assistance, please call 781-902-8400 ext. 4009 or email: diagnosticimaging@angell.org.