Name: Central Veterinary Services
Address: 8092 Perimeter Hwy, Oak Bluff, MB, R0G 1N0, Canada
Telephone: 204-275-2038
Price range: $

Thank you for trusting Central Veterinary Services with your patient’s care.

Please complete this form and attach all relevant medical records, laboratory results, and diagnostic imaging to support a thorough and timely assessment.

Once the referral and supporting records have been reviewed, our team will contact the client directly to coordinate scheduling. Please allow 24–48 business hours for processing.

If the case is urgent, we encourage you to contact us directly at 204-275-2038.

Referring Hospital Information

Name of Referring Veterinary Clinic *

Name of Referring Veterinarian *

Clinic Phone Number *

Clinic Email Address *

Client Information

Client Name *

First

Last

Primary Phone Number *

Alternate Phone Number

Email Address *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Patient Information

Patients Name: *

Species *

Canine
Feline

Breed: *

Crossbreeds

Sex: *

Male
Female

Reproductive Status *

Neutered
Not Neutered
Unknown

Age or Date of Birth *

Coat Colour *

Microchip #

Tattoo #

Allergies

Weight (kg) *

Clinical History & Indication

Ultrasonography is a non-invasive diagnostic tool that allows for detailed evaluation of abdominal organs, including size, shape, texture, position, and vascular supply. It supports timely diagnosis and informed clinical decision-making.

Our examinations are performed by experienced veterinarians using advanced diagnostic equipment. Please note that scans are not interpreted by a board-certified radiologist.

Tentative Diagnosis / Primary Concern *

Area of Interest *

Complete Abdominal Ultrasound
Urogenital Ultrasound (Urinary bladder and kidneys)
Pregnancy Ultrasound (Must be 30 day pregnant or greater)

** Please note - at this time we do not perform ultrasound examinations for the purpose of liver shunt documentation

Brief Medical History *

Current Medications & Supplements *

Relevant Lab Findings *

Relevant Radiographic Findings *

client, of Relevant

Additional Requests

If a mass is identified, do you request ultrasound-guided FNA (if appropriate)?* *

Yes
No

Samples will be processed in our in-house Cytoreader, and results forwarded with the ultrasound report.

If there are bleeding concerns, please indicate below

If there are concerns for hemorrhage in this patient, please indicate below:

Specific Questions You Would Like Addressed

Sedation Authorization

Do we have authorization to administer sedation if required? *

Yes
No

If sedation is anticipated, please indicate reason, concerns, or drug preferences

Important Notes & Confirmations

To ensure a smooth experience for both your team, our team, and the client, please confirm the following have been discussed with your client in advance of the appointment:

Previous medical records and relevant diagnostic imaging must be received and reviewed prior to booking.
The patient must be fasted for 12 hours prior to the procedure (unless otherwise directed).
The abdomen will be shaved for the ultrasound.
Sedation may be recommended to ensure patient comfort and safety.
Ultrasound results will be forwarded to the referring veterinarian within 24 hours.
Ultrasound findings will be communicated directly to the referring veterinarian. We will not review results with the client unless urgent medical circumstances require immediate discussion.

Medical Records Upload *

Drag & Drop Files, Choose Files to Upload

Please attach all relevant medical records, laboratory results, and diagnostic imaging.

Declaration

Declaration *

I confirm that the information provided is accurate and complete to the best of my knowledge.

Declaration *

I have read and understood the Privacy Policy.

We appreciate the opportunity to collaborate in your patient’s care.

Ultrasound Referral Form

Fill out the form below.

Referring Hospital Information

Client Information

Patient Information

Clinical History & Indication

Additional Requests

Sedation Authorization

Important Notes & Confirmations

Declaration

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