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Ultrasound Referral Form

Owners Name*

First

Last
Date of U/S appointment*

MM slash DD slash YYYY
Pet's Name
Sex*
Age*
Species*
- Canine
- Feline
Breed*
Referring Clinic
Referring Doctor
Reason for ultrasound/brief history
Differential Diagnosis
Current Medications
Medical records for review (please mark all that apply)*
- Medical History
- Urinalysis
- Radiographs
- Urine culture
- CBC/chemistry
- Previous Ultrasound
Ultrasound Procedure (Please mark the ultrasound you have recommended to the owner)*
- Focused Urinary System (kidneys, bladder, prostate)
- Full Ultrasound
- Focused (fluid and/or tumor check)
For pricing information, please call 414-897-8840.
Additional diagnostics requested (aspirate, cystocentesis, etc.)
Any additional comments
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1
Call us or schedule an appointment online.
2
Meet with a doctor for an initial exam.
3
Put a plan together for your pet.

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Mayfair Animal Hospital & ER

414-897-8840

11637 W. North Ave.
Wauwatosa, WI 53226

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Home
Our Hospital
Services
Referring Veterinarians
- Vet Referral Form
Payment Options
Online Pharmacy
Contact Us

Monday

10:00am - 10:00pm

Tuesday

10:00am - 10:00pm

Wednesday

10:00am - 10:00pm

Thursday

10:00am - 10:00pm

Friday

10:00am - 10:00pm

Saturday

10:00am - 10:00pm

Sunday

10:00am - 10:00pm

* Please call ahead, as availability may vary

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