Submit Patient Form

Submit Patient Form

Call or Text Us To Schedule An Appointment!

360-803-3303

…then fill out the form below

Important Scheduling Info:

  • Appointments are scheduled for a specific date, but arrival time will vary based upon number of appointments, traffic, add-on’s etc. If you need special accommodations, please indicate below in the scheduling requests box.

Important Appointment Info:

  • We will call when we are ~ 20 minutes away to allow for patient prep & sedation (if needed)
  • We will check-in @ the front desk upon arrival
  • At time of scan, we will determine if shaving will be needed (we are happy to do for you!)

Important Report Info:

  • Once the report is available, we will forward it to the email you indicated on this submission form
Our Services Questions? Contact Us

Patient Form

Request an Appointment

Referral Practice Information

Routine or STAT?
** STAT based upon availability @ time of scan
Services Requested
Practice Address (Only Fill Out If Our First Visit With You)
Practice Address (Only Fill Out If Our First Visit With You)
City
State/Province
Zip/Postal

Patient details

Patient Name
Patient Name
First
Last
Sex
Is this patient fractious & will need sedation?
** If sedation is needed, please have a plan in place at time of visit – IM injections should be given prior to sonographer arrival. ** Certain medications are not indicated for cardiac ultrasound – please contact us if you have questions
Not Guaranteed but will do our best to try and accomodate

Maximum file size: 516MB

Start Over
Scheduling or Questions?