Diagnostic Imaging Request Form Referring Veterinarian Information Elm Veterinary ClinicMontowese Veterinary ClinicNorthford Veterinary ClinicSpring Glen Veterinary ClinicVeterinary Associates of DerbyVeterinary Associates of North BranfordVeterinary Associates of WestvilleVeterinary Wellness Center of New Haven How would you like to be contacted about this case?PhoneFaxEmail Client Information Patient Information SPECIES: Avian/ExoticCatDogOther SEX: FFSMMNUnknown Imaging Procedure Requested (Check all that apply)RadiographsUltrasoundCT Radiographs Thorax3 View StandardOther:VDDVR LatL LatAbdomen3 View StandardOther:VDDVR LatL LatLower Urinary TractVDObliqueLatLat x2 (Males)Lat w/ CompressionWhole Body ScreenVDlatSpineC1-C5C6-T2T3-L3L3-S1TailVDLatFlexedNeutralExtendedOther:SkullOralNasalTMJBullaSinusOther:Musculoskeletal Which Views? 2 View StandardLat OFA Pelvis Elbow RLBoth Additional Views Flexed Lateral Other Ultrasound AbdomenFull CT Pertinent clinical history/lab data/differential diagnoses: Special Instructions/Orders/Cautions Please attach any documents or images related to this case below.You may also fax any information to 203-867-5195