ULTRASOUND REFERRAL
4390 East Main Street
Farmington, New Mexico, 87402
Valley Veterinary Clinic Pet Lodge & Salon
Phone: 505-326-2237
Fax: 505-564-8606
info@valleyvetpet.com
Today‘s Date:
Owner’s Name:
Owner’s Phone:
Patient Name:
Referring Veterinarian:
Circle: Canine Feline F F/S M M/N
Breed:
Age:
Weight:
Hospital Name:
Hospital Phone:
Hospital Fax:
Ultrasound Evaluation Report: Abdominal
Reproductive
Thoracic
Bladder
Bladder/Kidneys
Fine Needle Aspirate
Brief History/Complaint:
Clinical Lab work and Findings:
Bloodwork or Radiographic Abnormalities:
Please indicate items being sent with client:
Radiographs
Lab work
Medical Records
Faxing lab work / Medical records
Emailing lab work/Medical records.
Animal’s Temperament:
Sedation Required:
YES
NO
Please list any known anesthetic problems, pain drug reactions or current medications:
Contact Method for Appointment:
Referral practice will call
Owner will call
Valley Vet Clinic will call to schedule appt.
Results available within 24 hours by:
Fax
Postal Mail
Email
Please have Ultrasonographer call@
Please provide Estimate of cost to Client
(Please Initial)
Valley Veterinary Clinic, Pet Lodge & Salon, INC
4390 East Main
Farmington, NM 87402
Phone: 505-326-2237
Fax: 505-564-8606
info@valleyvetpet.com
Instructions for Ultrasound Referral Appointment:
 Please arrive 15 minutes prior to your scheduled appointment time so we may complete your medical record.
 Please do not feed your pet for 12 hours prior to the appointment.
 Please do not let animal urinate 2-3 hours prior to abdominal/bladder ultrasound
 Payment is due when services are rendered. For your convenience we accept Visa, MasterCard, American
Express, Discover, Care Credit, Personal Checks (Driver’s license number necessary) and Cash. Be reminded
taxes is not included in prices below.
Abdominal- $322.51
Cardiac/Thoracic- $322.51
Bladder - $139.03
Bladder/Kidneys- $139.03
Reproductive -$139.03
Fine needle Biopsies –Individual Basis
 Sedation may be required in some cases in order to obtain better images and can be done at extra cost of
$45.00-60.00. Additional cost of gas anesthesia required
Directions to Clinic:
Valley Veterinary Clinic-Pet Lodge & Salon is located at 4390 E. Main (Highway 550) at the intersection of Main and
Largo across from Starbucks near the Animas Valley Mall.
We appreciate the trust that you and your veterinarian have placed in us. We will do all that we can to ensure that
your visit to our hospital exceeds your expectations