Referral Form

Please contact AMII for availability before scheduling a case with the owner.
Discuss the possibility of ultrasound-guided fine needle aspirates with the owner prior to the ultrasound if aspirates are anticipated and desired. A PCV/TS and platelet count should be performed at a minimum before aspirates will be performed. Biopsies are not offered by AMII.
Fasting on the day of ultrasound is preferred unless patients are diabetic or very pediatric. Water should not be restricted unless directed otherwise.
By noon the day before consultation: confirm appointments with owners and forward lab results/ radiographs/ relevant records to Dr. Lomas.
At the time of patient drop-off, get approval for shaving and sedation, if necessary.
Veterinary clinics will be invoiced directly for services rendered.

Referring Veterinary Hospital *

Phone *

Hospital Email *

Confirmation and reports will be sent to this email.

Referring Veterinarian *

RDVM Email

Optional secondary email (If different from hospital email). Confirmation and reports will be cc’d here.

Patient Name *

First

Last

Signalment *

(Age, Sex, Breed, Species)

Weight *

Specify units (lbs or kg)

Weight Change *

Note any recent weight gain or loss. Specify units (lbs or kg)

Clinical Concern(s) *

(Problem or Indication for Ultrasound)

Pertinent History *

(Note Clinical Signs, Duration, and Progression if Applicable)

Diagnostics Performed and Relevant Results *

(Please email complete lab work and/or radiographs separately. Include patient name in email subject line.)

Current/ Recent Medications *

(Drug/ Dosage/ Frequency)

Diet *

Current diet and the diet that preceded illness.

Name