Submit a Referral

Department Referring to*
- Emergency
- Behaviour
- Cardiology
- Neurology
- Dentistry/Oral Surgery
- Diagnostic Imaging: Outpatient (stable) abdominal ultrasound
- Emergency Ultrasound
- Ophthalmology
- Surgery
- Internal Medicine
Consent to perform an internal referral without contacting you*
- Yes
- No
Acknowledgement*
I understand this form is to request an outpatient abdominal ultrasound for a STABLE patient. Once we receive all relevant medical records, a staff member will contact your client to arrange a time to perform the abdominal ultrasound, usually within the next 2-5 business days. A report with the ultrasound findings will be emailed to the clinic address provided by the end of the day the scan is performed. Cytology results (if performed) will be forwarded as soon as they arrive at Pulse. Please note that if fine needle aspirates are requested, a recent platelet evaluation (Complete Blood Count/CBC) must be sent to Pulse prior to the ultrasound appointment. Ultrasound and cytology results are sent to the referring DVM only and are not discussed with owners.
Acknowledgement*
I understand emergency ultrasounds are triaged and managed by the ER department and can typically be performed within 24hrs of a patient arriving in our hospital.
Patient to be seen*
- Next available appointment
- Next 24 hours
- Emergency (in addition to this form submission please also call Pulse to let us know about the case)
Referring Hospital Information:
Referring hospital name*
Primary care DVM name*
Hospital phone*
Hospital fax
Hospital Email*
Preferred method of communication*
- Phone
- Fax
- Email
Client Information
Client Name*
Partner/Co-owner Name
Client Phone*
Secondary Phone
Client Email
Address*
Street Address Address Line 2 City Province Postal Code
Patient Information
Patient name*
Date of Birth
MM slash DD slash YYYY
or Age
Years Months
Species*
Breed
Colour
Sex*
- M
- MN
- F
- FS
- Unknown
Weight (kg)*
Does the patient have pet insurance?*
- Yes
- No
If yes; with which company? What has this current condition been submitted as? *PLEASE BE SPECIFIC AND INCLUDE ALL THE CONDITIONS FOR THIS CLAIM*
Documents to be sent*
- Medical Records
- Lab Results
- Radiographs
- Dental Radiographs
- Other
Documents to be sent*
- Medical Records
- Lab Results
- Lab Results: CBC
- Lab Results: Chem
- Lab Results: UA
- Lab Results: Clotting times
- Lab Results: Cytology
- Radiographs
- Dental Radiographs
- Other
Other Document(s)
Documents sent via*
- Email
- Fax
- Sent with Client
- Uploaded to this form
- Other
Other method documents sent
Documents Attached
- Radiographs
- Bloodwork
File*
Drop files here or

Max. file size: 18 MB, Max. files: 10.
Notes
Presenting complaint or tentative diagnosis*
Relevant history and physical examination findings*
Reason for/goal of abdominal ultrasound*
Important diagnostics findings*
Treatments and medications (dose, frequency, last dose)*
Have you discussed fine needle aspirate/organ sampling with the client?*
- Yes
- No
Are there any samples you would like collected? (eg. Fluid collection, organ aspirate, cystocentesis)*
Do you have a preferred doctor?
Requests/comments
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Consent*
By submitting this form you are giving Pulse Veterinary Specialists & Emergency consent to use and store the information contained within this form.
I Agree
Phone
This field is for validation purposes and should be left unchanged.

For referral of a patient please use the online referral form. We will contact the owner to schedule a consultation.

Referral Form

Referring Hospital Information:

Client Information

Patient Information

Notes

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