Diagnostic Imaging Request Form

    Referring Veterinarian Information

    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

    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


    Please attach any documents or images related to this case below.
    You may also fax any information to 203-867-5195