Diagnostic Imaging Request Form

Referring Veterinarian Information

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Client Information




Patient Information


SPECIES: Avian/ExoticCatDogOther

SEX: FFSMMNUnknown


Imaging Procedure Requested (Check all that apply)

RadiographsUltrasoundCT

Radiographs

Thorax
3 View Standard
Other:VDDVR LatL Lat
Abdomen
3 View Standard
Other:VDDVR LatL Lat
Lower Urinary Tract
VDObliqueLatLat x2 (Males)Lat w/ Compression
Whole Body Screen
VDlat
Spine
C1-C5C6-T2T3-L3L3-S1Tail
VDLatFlexedNeutralExtended
Other:
Skull
OralNasalTMJBullaSinus
Other:
Musculoskeletal


   Which Views?
   2 View StandardLat
   OFA
      Pelvis
      Elbow
         RLBoth
   Additional Views
      Flexed Lateral
      
      
Other

Ultrasound

Abdomen
Full




CT




Pertinent clinical history/lab data/differential diagnoses:

Special Instructions/Orders/Cautions


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