Radiology Referral Form


*Required

Referring Veterinarian Information




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Client Information




Patient Information


SPECIES: Avian/ExoticCatDogOther

SEX: FFSMMNUnknown

Reason for Referral(including relevant history, clinical findings and lab data)

Test to be Performed

Ultrasound
AbdomenNon-cardiac ThoraxNeckOther

Radiography/Contrast Procedure

CT Scan


Please inform the owner of the following

Food should be withheld for 12-15 hours prior to the procedure for optimal image quality and in the case that sedation/anesthesia is required. If this is not possible for medical reasons, please contact us. Withholding water is not necessary.

For ultrasonographic procedures, the area of interest will be shaved to optimize image quality and maximize the diagnostic potential of the test.

For other tests, please call us for specific preparatory instructions.

Owners will not be given the results of the imaging procedures performed except under certian, critical circumstances. The owners will be asked to contact your office for imaging results, and to make plans for further actions. This is to keep you in control of your case and to simplify communications.

If you wish to have another doctor at our facility go over the imaging results with the owner and make further recommendations, please speak to the imaging department to set up the appropriate consultation.

Biopsies, needle aspirates and other interventional procedures are not scheduled as outpatient procedures and cannot be performed as an add-on to an outpatient exam except in critical cases where the case is transferred to a staff doctor for case management. Routine, non-emergent procedures can be scheduled through the imaging department as day-admits. Please call us for more information.


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You may also fax any information to 203-867-5195