Outpatient Ultrasound Referral

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Outpatient Ultrasound Referral

Outpatient Ultrasound Referral Form

Mahalo for submitting a PAH referral request. Please be aware that submitting a referral request does not guarantee your patient can be seen with us. We are only able to accept non-client referral requests if our schedule has availability.

* Indicates required field

Referring veterinary clinic *

referring dvm *

Referring DVM PHONE *

Referring DVM EMAIL *

We will send the ultrasound diagnostic report to this email

Client Name *

First

Last

Client Phone *

Client Email *

Patient name *

Patient Species *

Patient Breed *

Patient Age *

patient weight *

Patient Sex *

ULTRASOUND REQUEST *

Abdominal ultrasound Basic thoracic ultrasound

Referral Request Expectation *

Diagnostics report including a consultation with recommendations in order to continue care at current PDVM Diagnostics report including a consultation with recommendations and possible further treatment at PAH

Ultrasound scheduling urgency *

Emergency (1-3 days) *emergency fee may be applied Semi-urgent (1-2 weeks) Non-urgent (3 + weeks)

An emergency fee may be applied based on how busy our existing schedule is. If we are squeezing in an urgent ultrasound referral into a completely booked schedule, the emergency fee can range from $80-$170

PDVM SUSPECTED DIAGNOSIS *

Does PAH have consent to perform a FNA (fine needle aspirate) based on DVM's recommendation? *

Yes No

Relevant medical details and reason for referral *

Specify patient's current medication and any drug allergies (if applicable) *

Do you recommend against sedating this patient due to medical reasons? If so, explain why. *

Upload relevant medical records *

Max file size: 20MB

Upload additional recent diagnostics (within 30 days) *

Max file size: 20MB

Client was made aware to fast patient of food for 12 hours prior to ultrasound (do not fast water) *

Yes No

Client was made aware that payment for PAH referral is due at time of service *

Yes No

Submit

***Relevant medical records (include full DVM notes) and relevant diagnostics are REQUIRED. PAH will NOT review referral requests without these submitted***

Find us!

15-2714 Pahoa Village Rd. Unit C3.
Pahoa, Hawaii 96778
Office: 808.930.5888
Fax: 808.930.5889
[email protected]

Hours of Operation:

Monday 8:00 am - 5:00 pm
Tuesday 8:00 am - 5:00 pm
Wednesday 8:00 am - 5:00 pm
Thursday 8:00 am - 5:00 pm
Friday 8:00 am - 5:00 pm
Saturday - Closed
Sunday - Closed