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Ultrasound Request Form

Veterinary staff, please fill out the form below to request an outpatient ultrasound for your patient. We will contact them upon submission to set an appointment. We often have same day or next day availability so please do not hesitate to contact us via call or text to 720.442.8350, if there are any questions, or if you have an urgent case. Please email your patient’s pertinent records/diagnostics to Contact@EclipseVetImaging.com. Please see below for our anti-anxiety protocol.

Once the ultrasound has been performed, you will receive a report within a few hours.

Patient First and Last Name Patient Age Patient Breed

Patient sex

Male Neutered Female Spayed Male Intact Female Intact

Please provide the patient’s current medical history/reason for ultrasound. Client’s First and Last Name Client’s Phone Number Please provide a list of any known medical conditions, past or present, that the patient may have. Please provide the last date of blood work and any abnormalities.

Were any previous diagnostic imaging performed? if yes, please send images/reports to Contact@EclipseVetImaging.com.

Yes No

Are there any behavioral or other concerns we should be aware of? Referring Veterinary Hospital/Clinic Name Referring Veterinarian First and Last Name Which email(s) would you like the reports be delivered to?

If a Fine Needle Aspirate is needed, would you like Eclipse to submit the cytology with our in-house Imagyst? Results are reportied within 24 hours.

Yes No

Are you an Eclipse Veterinary Imaging Affiliate Program Partner and have you collected payment from your client?

Yes No

If Not, would you like more information regarding the program which gives you preferred pricing?

Yes No

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Our board-certified Veterinary Radiology Specialists provide ultrasound and teleradiology services. You can expect compassionate, expert and affordable care from our team.