{"id":161,"date":"2025-10-20T16:50:47","date_gmt":"2025-10-20T03:50:47","guid":{"rendered":"https:\/\/www.nzradvet.co.nz\/?page_id=161"},"modified":"2025-10-20T16:52:06","modified_gmt":"2025-10-20T03:52:06","slug":"ultrasound-outpatient-request-form","status":"publish","type":"page","link":"https:\/\/www.nzradvet.co.nz\/index.php\/ultrasound-outpatient-request-form\/","title":{"rendered":"Ultrasound Outpatient Request Form"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; theme_builder_area=&#8221;post_content&#8221; _builder_version=&#8221;4.27.0&#8243; _module_preset=&#8221;default&#8221;][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; theme_builder_area=&#8221;post_content&#8221; _builder_version=&#8221;4.27.0&#8243; _module_preset=&#8221;default&#8221;][et_pb_row _builder_version=&#8221;4.27.0&#8243; _module_preset=&#8221;default&#8221; theme_builder_area=&#8221;post_content&#8221;][et_pb_column _builder_version=&#8221;4.27.0&#8243; _module_preset=&#8221;default&#8221; type=&#8221;4_4&#8243; theme_builder_area=&#8221;post_content&#8221;][et_pb_heading title=&#8221;Ultrasound Outpatient Request Form&#8221; _builder_version=&#8221;4.27.0&#8243; _module_preset=&#8221;default&#8221; theme_builder_area=&#8221;post_content&#8221; title_text_align=&#8221;center&#8221; title_font=&#8221;|700|||||||&#8221; hover_enabled=&#8221;0&#8243; sticky_enabled=&#8221;0&#8243;][\/et_pb_heading][wpforms_selector _builder_version=&#8221;4.27.0&#8243; _module_preset=&#8221;default&#8221; theme_builder_area=&#8221;post_content&#8221; form_id=&#8221;156&#8243; hover_enabled=&#8221;0&#8243; sticky_enabled=&#8221;0&#8243;][\/wpforms_selector][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<div class=\"et_pb_module wpforms_selector wpforms_selector_0\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t<style id=\"wpforms-css-vars-156\">\n\t\t\t\t#wpforms-156 {\n\t\t\t\t--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-156\"><form id=\"wpforms-form-156\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"156\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/161?wpforms_form_id=156\" data-token=\"0d05e226a294e832c274561bc34bfb9e\" data-token-time=\"1778067189\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-156-field_29-container\" class=\"wpforms-field wpforms-field-radio wpforms-conditional-trigger\" data-field-id=\"29\"><fieldset><legend class=\"wpforms-field-label\">Would you like<\/legend><ul id=\"wpforms-156-field_29\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-156-field_29_1\" name=\"wpforms[fields][29]\" value=\"The patient to travel to our Feilding clinic\" aria-errormessage=\"wpforms-156-field_29_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-156-field_29_1\">The patient to travel to our Feilding clinic<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-156-field_29_2\" name=\"wpforms[fields][29]\" value=\"A visit to your clinic if possible (Manawatu, Whanganui, Kapiti coast)\" aria-errormessage=\"wpforms-156-field_29_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-156-field_29_2\">A visit to your clinic if possible (Manawatu, Whanganui, Kapiti coast)<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-156-field_30-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"30\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Would you like us to<\/legend><ul id=\"wpforms-156-field_30\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-156-field_30_1\" name=\"wpforms[fields][30][]\" value=\"Discuss the case &amp; estimate with the referring veterinarian first\" aria-errormessage=\"wpforms-156-field_30_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-156-field_30_1\">Discuss the case &amp; estimate with the referring veterinarian first<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-156-field_30_2\" name=\"wpforms[fields][30][]\" value=\"Contact the owner directly to arrange referral\" aria-errormessage=\"wpforms-156-field_30_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-156-field_30_2\">Contact the owner directly to arrange referral<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-156-field_31-container\" class=\"wpforms-field wpforms-field-html wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"31\" style=\"display:none;\"><div id=\"wpforms-156-field_31\" aria-errormessage=\"wpforms-156-field_31-error\"><strong>We will contact you to arrange a time<\/strong><\/div><\/div><div id=\"wpforms-156-field_3-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"3\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-156-field_1-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-156-field_1\">Clinic Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-156-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" aria-errormessage=\"wpforms-156-field_1-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-156-field_2-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-156-field_2\">Clinic Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-156-field_2\" class=\"wpforms-field-medium wpforms-field-required\" data-disable-suggestions=\"1\" name=\"wpforms[fields][2]\" spellcheck=\"false\" aria-errormessage=\"wpforms-156-field_2-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-156-field_4-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-156-field_4\">Clinic Phone<\/label><input type=\"tel\" id=\"wpforms-156-field_4\" class=\"wpforms-field-medium\" data-rule-int-phone-field=\"true\" name=\"wpforms[fields][4]\" aria-label=\"Clinic Phone\" aria-errormessage=\"wpforms-156-field_4-error\" ><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-156-field_5-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-156-field_5\">Veterinarian\u2019s Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-156-field_5\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][5]\" aria-errormessage=\"wpforms-156-field_5-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-156-field_6-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-156-field_6\">Veterinarian\u2019s Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-156-field_6\" class=\"wpforms-field-medium wpforms-field-required\" data-disable-suggestions=\"1\" name=\"wpforms[fields][6]\" spellcheck=\"false\" aria-errormessage=\"wpforms-156-field_6-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-33\"><div id=\"wpforms-156-field_7-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-156-field_7\">Veterinarian\u2019s Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-156-field_7\" class=\"wpforms-field-medium wpforms-field-required\" data-rule-int-phone-field=\"true\" name=\"wpforms[fields][7]\" aria-label=\"Veterinarian\u2019s Phone\" aria-errormessage=\"wpforms-156-field_7-error\" required><\/div><\/div><\/div><\/div><\/div>\t\t<div id=\"wpforms-156-field_17-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"17\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-156-field_17\" >Layout Veterinarian\u2019s Patient<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-156-field_17\" class=\"wpforms-field-medium\" name=\"wpforms[fields][17]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-156-field_8-container\" class=\"wpforms-field wpforms-field-layout\" data-field-id=\"8\"><div class=\"wpforms-field-layout-rows wpforms-field-large\"><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-156-field_9-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-156-field_9\">Patient Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-156-field_9\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][9]\" aria-errormessage=\"wpforms-156-field_9-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-156-field_10-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-156-field_10\">Owner&#039;s Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-156-field_10\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][10]\" aria-errormessage=\"wpforms-156-field_10-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-156-field_11-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-156-field_11\">Owner&#039;s Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-156-field_11\" class=\"wpforms-field-medium wpforms-field-required\" data-disable-suggestions=\"1\" name=\"wpforms[fields][11]\" spellcheck=\"false\" aria-errormessage=\"wpforms-156-field_11-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-156-field_12-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-156-field_12\">Owner&#039;s Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-156-field_12\" class=\"wpforms-field-medium wpforms-field-required\" data-rule-int-phone-field=\"true\" name=\"wpforms[fields][12]\" aria-label=\"Owner&#039;s Phone\" aria-errormessage=\"wpforms-156-field_12-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-156-field_13-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-156-field_13\">Species <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-156-field_13\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][13]\" aria-errormessage=\"wpforms-156-field_13-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-156-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-156-field_14\">Breed <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-156-field_14\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][14]\" aria-errormessage=\"wpforms-156-field_14-error\" required><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-156-field_15-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-156-field_15\">Age <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-156-field_15\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][15]\" aria-errormessage=\"wpforms-156-field_15-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-156-field_18-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"18\"><fieldset><legend class=\"wpforms-field-label\">Sex <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-156-field_18\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-156-field_18_1\" name=\"wpforms[fields][18]\" value=\"F\" aria-errormessage=\"wpforms-156-field_18_1-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-156-field_18_1\">F<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-156-field_18_2\" name=\"wpforms[fields][18]\" value=\"M\" aria-errormessage=\"wpforms-156-field_18_2-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-156-field_18_2\">M<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-156-field_18_3\" name=\"wpforms[fields][18]\" value=\"FS\" aria-errormessage=\"wpforms-156-field_18_3-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-156-field_18_3\">FS<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-156-field_18_4\" name=\"wpforms[fields][18]\" value=\"MN\" aria-errormessage=\"wpforms-156-field_18_4-error\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-156-field_18_4\">MN<\/label><\/li><\/ul><\/fieldset><\/div><\/div><\/div><div class=\"wpforms-layout-row\"><div class=\"wpforms-layout-column wpforms-layout-column-50\"><div id=\"wpforms-156-field_16-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-156-field_16\">Weight <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-156-field_16\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][16]\" aria-errormessage=\"wpforms-156-field_16-error\" required><\/div><\/div><div class=\"wpforms-layout-column wpforms-layout-column-50\"><\/div><\/div><\/div><\/div><div id=\"wpforms-156-field_27-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-156-field_27\">Relevant Clinical History:<\/label><textarea id=\"wpforms-156-field_27\" class=\"wpforms-field-medium\" name=\"wpforms[fields][27]\" aria-errormessage=\"wpforms-156-field_27-error\" ><\/textarea><\/div><div id=\"wpforms-156-field_19-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"19\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-156-field_19\" aria-hidden=\"false\">Upload File History:<\/label><div\n\t\tclass=\"wpforms-uploader \"\n\t\tdata-field-id=\"19\"\n\t\tdata-form-id=\"156\"\n\t\tdata-input-name=\"wpforms_156_19\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,x-wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages\"\n\t\tdata-max-size=\"16777216\"\n\t\tdata-max-file-number=\"5\"\n\t\tdata-post-max-size=\"16777216\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div 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Upload<\/span>\n\t\t\t\t\t<\/span>\n\n\t\t\t\t\t<span class=\"modern-hint\">You can upload up to 5 files.<\/span>\n\t\t\t<\/div>\n<\/div>\n\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-156-field_19\"\n\t\tname=\"wpforms_156_19\" \t\tvalue=\"\">\n<div id=\"wpforms-156-field_19-description\" class=\"wpforms-field-description\">(Please include any attachments or recent blood results, histology etc)<\/div><\/div><div id=\"wpforms-156-field_26-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-156-field_26\">Study Required<\/label><input type=\"text\" id=\"wpforms-156-field_26\" class=\"wpforms-field-medium\" name=\"wpforms[fields][26]\" 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