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Outpatient Referral Form

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Radiology Outpatient Ultrasound Referral Form

DVMS would like to thank you for your referrals and continued partnership.

In order to streamline our radiology outpatient ultrasound referral process and provide the best experience for your clients and patients, we ask that this form be returned within 24 business hours and include the following:

  • Pertinent medical records AND labwork
  • Pertinent radiographs and/or reports
  • Any other information pertinent to the patient’s medical needs/concerns
  • We recommend that you provide pre-appointment
    oral sedation (ie, Gabapentin, Trazadone) – if none is dispensed to
    your client, please provide us with IV sedation recommendations

This referral form along with all the requested records must be received before any outpatient ultrasounds will be scheduled.

If you have any questions or concerns, please call us at 480-454-4373, ext. 3.

This form is MANDATORY for all outpatient ultrasounds offered by DVMS to help ensure that we assist in the care of your patient in the best way possible. Please return this form with the below items via email or fax to the above listed locations. Our ultrasound report will be emailed to you to assist in your follow-up treatment.


This referral form along with all the requested records must be received before any outpatient ultrasounds will be scheduled with your client.

  • Pertinent medical records AND labwork
  • Pertinent radiographs and/or reports
  • Any other information pertinent to the patient’s medical needs/concerns
  • We recommend that you provide pre-appointment oral sedation – if none is dispensed to your client, please provide us with IV sedation recommendations in the provided space above.
Signature of person who completed this form(Required)