[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-0-en-105":3,"doc-seo-400616-105":59,"doc-detail-400616-en":131},{"code":4,"msg":5,"data":6},0,"success",[7,13,18,23,28,33,38,43,48,51,55],{"id":8,"doc_module":4,"doc_module_name":9,"category_name":10,"show_sort_weight":11,"slug":12},1,"Document","Story & Novel",90,"story-novel",{"id":14,"doc_module":4,"doc_module_name":9,"category_name":15,"show_sort_weight":16,"slug":17},2,"Literature",80,"literature",{"id":19,"doc_module":4,"doc_module_name":9,"category_name":20,"show_sort_weight":21,"slug":22},4,"Exam",70,"exam",{"id":24,"doc_module":4,"doc_module_name":9,"category_name":25,"show_sort_weight":26,"slug":27},5,"Comic",60,"comic",{"id":29,"doc_module":4,"doc_module_name":9,"category_name":30,"show_sort_weight":31,"slug":32},6,"Technology",50,"technology",{"id":34,"doc_module":4,"doc_module_name":9,"category_name":35,"show_sort_weight":36,"slug":37},7,"Healthcare",40,"healthcare",{"id":39,"doc_module":4,"doc_module_name":9,"category_name":40,"show_sort_weight":41,"slug":42},8,"Research & Report",30,"research-report",{"id":44,"doc_module":4,"doc_module_name":9,"category_name":45,"show_sort_weight":46,"slug":47},9,"Religion & Spirituality",20,"religion-spirituality",{"id":46,"doc_module":4,"doc_module_name":9,"category_name":49,"show_sort_weight":46,"slug":50},"World Cup","world-cup",{"id":52,"doc_module":4,"doc_module_name":9,"category_name":53,"show_sort_weight":52,"slug":54},10,"Lifestyle","lifestyle",{"id":56,"doc_module":4,"doc_module_name":9,"category_name":57,"show_sort_weight":24,"slug":58},19,"General","general",{"code":4,"msg":60,"data":61},"ok",{"site_id":62,"language":63,"slug":64,"title":65,"keywords":66,"description":67,"schema_data":68,"social_meta":124,"head_meta":126,"extra_data":128,"updated_unix":130},105,"en","ultrasound-scheduling-and-referral-exam-form-appointment-preparation-instructions","ULTRASOUND - Scheduling and Referral Exam Form - Appointment Preparation Instructions","","Ultrasound referral and appointment form for patient scheduling, check-in, and exam selection, including abdomen/pelvis, OB ultrasound, and multiple specialty options such as vascular, liver, transplant-related studies, and other targeted ultrasound types. Includes required patient information fields, a sign/symptom requirement note, provider signature and stat report options (fax or call). Provides detailed adult preparation instructions by exam type, including fasting and hydration rules, bladder fullness guidance for kidney/obstetrical/pelvic exams, visitor and child supervision rules, medication guidance, and restrictions on video or photography.",{"@graph":69,"@context":123},[70,84,106],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/ultrasound-scheduling-and-referral-exam-form-appointment-preparation-instructions/400616/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/ultrasound-scheduling-and-referral-exam-form-appointment-preparation-instructions/400616.png","ImageObject",300,407,{"name":92,"@type":93},"Aran","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-29","2026-09-27",true,{"@type":102,"interactionType":103,"userInteractionCount":105},"InteractionCounter",{"@type":104},"ViewAction",11,{"@type":107,"mainEntity":108},"FAQPage",[109,115,119],{"name":110,"@type":111,"acceptedAnswer":112},"What should I bring to the ultrasound appointment?","Question",{"text":113,"@type":114},"Bring the completed form with you, as required for the exam.","Answer",{"name":116,"@type":111,"acceptedAnswer":117},"How should I prepare for an adult abdominal ultrasound?",{"text":118,"@type":114},"Follow a low-fat diet the night before, drink at least 4 glasses of water the day before, and fast for at least 8 hours before the exam time. Medications can be taken with a small amount of water.",{"name":120,"@type":111,"acceptedAnswer":121},"What bladder preparation is required for kidney, obstetrical, and pelvic ultrasounds?",{"text":122,"@type":114},"Kidney: drink 12 ounces of water one hour before and do not empty your bladder. Obstetrical: use full-bladder guidance with specified ounces at set times depending on pregnancy weeks. Pelvis: finish drinking 16 ounces 45 minutes before, avoid caffeine/coffee/tea/soda, and do not empty your bladder; internal scan may be required.","https://schema.org",{"og:url":83,"og:type":125,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":127,"canonical":83},"index,follow",{"doc_id":129,"site_id":62},400616,1790648345,{"code":4,"msg":5,"data":132},{"doc_id":129,"user_id":133,"nickname":92,"user_avatar":134,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":135,"file_id":136,"file_url":137,"file_type":138,"file_size":139,"view_count":105,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":14,"language":140,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":67,"update_tm":144,"read_time":24,"preview_page_count":4},137455076865,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","ULTRASOUND  \nScheduling Phone: 360-647-2422  \nToll Free: 800-767-0430  \nFax This Referral To: 360-255-2263  \n\n| \u003Cbr>YOU MUST BRING THIS FORM WITH YOU FOR US TO PERFORM YOUR EXAM. |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| APPOINTMENT INFORMATION (Check Appropriate Site) Appointment Date:  \u003Cbr>Check in Time:  \u003Cbr>Appointment Time:   See Location Map |  |  |  |  | o Northwest Avenue-4029 Northwest Ave, Ste. 201 |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  | \u003Cbr>\u003Cbr>\u003Cbr>\u003Cbr>\u003Cbr>W. KELLOG RD.\u003Cbr>|  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| \u003Cbr>1 | PATIENT INFORMATION (please print)\u003Cbr>Name:   DOB:   Telephone(s):   Referring Provider:  \u003Cbr>CC:   Insurance Company (s):   Patient’s Insurance ID \\#:   |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| \u003Cbr>2 | Abdomen/Pelvis – Preps required for all exams, please see back of form |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  | o o\u003Cbr>o o | Upper Abdomen Complete Aorta Only — AAA assessment Kidney / Bladder\u003Cbr>Kidney transplant\u003Cbr>o General o Vascular | o Liver without Portal Duplex Doppler\u003Cbr>o Liver with Portal Duplex Doppler\u003Cbr>o Liver Transplant\u003Cbr>o General o Vascular |  |  | o Pelvis with Endovaginal (with Duplex Doppler if needed)\u003Cbr>o No Endovaginal (for patients with contraindications) |  |  |  |  |  |  |  |  |\n| OB Ultrasound (w/endovaginal and/or duplex Doppler as needed) Preps required for all exams, please see back of form\u003Cbr>o OB 1st Trimester (with Nuchal Translucency if 11-14 wks)\u003Cbr>o No Nuchal Translucency needed\u003Cbr>o Nuchal Translucency Only\u003Cbr>o OB 2nd/3rd Trimester\u003Cbr>o Fetal Survey (recommend 18 weeks or greater)\u003Cbr>o Low Risk o High Risk Reason:  \u003Cbr>o Complete before18 weeks (anatomy will be limited)\u003Cbr>o Follow-up\u003Cbr>o Anatomy o Growth\u003Cbr>o Follow-up Limited (position, placenta, cervix, fluid only)\u003Cbr>o Biophysical Profile, w/ OB Limited\u003Cbr>o Include S/D ratios |  |  |  |  |  |  |  | Other – No Preps required\u003Cbr>o Hernia (site):  \u003Cbr>o Appendix/RLQ\u003Cbr>o Scrotal (with Duplex Doppler if needed)\u003Cbr>o Shoulder (specify R/L or bilateral)\u003Cbr>o Extremity Limited\u003Cbr>o Thyroid/Parathyroid/Neck\u003Cbr>o Thyroid FNA/Biopsy — Please specify nodule(s):\u003Cbr>o Infant Hips (4 weeks - 6 months “corrected gestational age”)\u003Cbr>o Infant Head (up to 12 months)\u003Cbr>o Infant Pyloric Stenosis (see scheduler for prep)\u003Cbr>o Infant Spine\u003Cbr>o Ophthalmic A-scan\u003Cbr>o Other:   |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n|  3 \u003Cbr>SIGN / SYMPTOM-Required ( No “rule out” or “suspected”) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n\nX   \nPROVIDER SIGNATURE REQUIRED  \nStat Report Desired (choose one)  \no Fax Report (Fax number required)    \no Call Report (Provider cell phone number required)    \nScheduling Phone: 360-647-2422  \nToll Free: 800-767-0430  \nFax This Referral To: 360-255-2263  \nULTRASOUND EXAM PREPARATION INSTRUCTIONS FOR ADULTS (Preparation instructions for CHILDREN should be obtained from a scheduler)  \nPlease follow these instructions to ensure a successful ultrasound exam.  \no ABDOMEN (Aorta, Bile Ducts, Gallbladder, Liver, Pancreas, Spleen) Allow1 hour  \n•The night before your exam follow a low fat diet and avoid gas producing foods.  \n•The day before your exam, drink a minimum of 4 glasses of water (not all at once) .  \n• Do NOT eat, drink, chew gum or smoke for at least 8 hours prior to your exam time. You will be fasting until your exam is completed. A small amount of water for medications is OK at any time.  \no KIDNEY (Renal) Allow 1 hour  \n• One hour before the exam drink 12 ounces of water.  \n• Do not empty your bladder after drinking the water.  \no OBSTETRICAL Allow 1 hour*  \n• Patients in the first half (up to 24 weeks) of pregnancy:  \n1. Finish drinking  16 ounces of water 45 minutes before your appointment.  \n2. Do not empty your bladder after drinking the water. A full bladder is important. ","cbCaioTbIUK8FeOj","https://ap.wps.com/l/cbCaioTbIUK8FeOj","pdf",189736,"English","# Appointment Information\n## Patient Information\n## Exam Type Selection\n## Provider Signature and Stat Report Options\n## Ultrasound Exam Preparation Instructions for Adults\n## Visitor and Patient Rules","[{\"question\":\"What should I bring to the ultrasound appointment?\",\"answer\":\"Bring the completed form with you, as required for the exam.\"},{\"question\":\"How should I prepare for an adult abdominal ultrasound?\",\"answer\":\"Follow a low-fat diet the night before, drink at least 4 glasses of water the day before, and fast for at least 8 hours before the exam time. Medications can be taken with a small amount of water.\"},{\"question\":\"What bladder preparation is required for kidney, obstetrical, and pelvic ultrasounds?\",\"answer\":\"Kidney: drink 12 ounces of water one hour before and do not empty your bladder. Obstetrical: use full-bladder guidance with specified ounces at set times depending on pregnancy weeks. Pelvis: finish drinking 16 ounces 45 minutes before, avoid caffeine/coffee/tea/soda, and do not empty your bladder; internal scan may be required.\"}]","ULTRASOUND - Scheduling and Referral Exam Form - Appointment Preparation Instructions | PDF",1790512633]