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This brief presents a monolithically integrated fully differential linear HV amplifier as the driver of an ultrasonic transducer. The linear amplifier is capable of transmitting HV arbitrary signals with a very low harmonic distortion, which is suitable for tissue harmonic imaging and other ultrasonic modes for enhanced imaging quality. The amplifier is designed and implemented using the 0.7-μm CMOS silicon-on-insulator process with 120-V devices. The amplifier, when driving a load of 300 pF in parallel with 100 Ω, is capable of transmitting a sine-wave signal with a frequency of up to 4.4 MHz, a maximum signal swing of 180 Vpp, and a second-order harmonic distortion (HD2) of −56 dBc but only dissipating an average power of 62 mW with a 0.1% duty cycle.