To make the process as efficient as possible, please fax or e-mail all current bloodwork, imaging and lab reports relevant to this case in advance of your appointment. Fax (802) 773-0485 or info@rutlandvet.com. If you have any questions please feel free to call us at (802) 773-2779. Thank you.

PRACTICE INFORMATION

Referring Practice *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Referring Veterinarian *

Practice E-mail *

Practice Phone *

PATIENT INFORMATION

Owner's Name *

First

Last

Phone *

Pet's Name *

Birthday/Age *

Species *

Dog
Cat

Breed *

Gender *

Male
Female

Neutered/Spayed *

Yes
No

Is this pet fractious? *

Yes
No

Our Ultrasonographer requires anti-anxiety medications for all patients prior to ultrasounds. We recommend a dose the night before the appointment and then again 2-3 hours before the appointment.

-For Cats – Gabapentin at a recommended dose of 100mg per average size cat

-For Dogs – Gabapentin at a recommended dose of 20-30 mg/kg

-Trazodone at a recommended dose of 5-8mg/kg

Were the anti-anxiety medications prescribed and communicated with the client? *

Yes
No

Is it safe for this pet to receive full sedation? *

Yes
No

Chief Complaints

Current Medications

Medical History

PE Findings

Clinical Diagnostics/Results

Differential Diagnoses/Organs of Interest

Which cavity is to be scanned? *

Abdomen
Cardiac

PRACTICE INFORMATION

PATIENT INFORMATION

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