New Patient Referral

  • 86 W. Juniper Ave. Suite 2 Gilbert, AZ 85233
  • 22595 N. Scottsdale Rd. Suite #120 Scottsdale, AZ 85225
  • 7823 W. Golden Lane West Entrance Peoria, AZ 85345
  • Referring Veterinary Hospital Information

  • Date Format: MM slash DD slash YYYY
  • Patient Information

  • General Information:
    This form is appreciated for all cardiology and internal medicine referrals and is mandatory for all outpatient services offered by radiology in addition to the Radiology Services Request Form. This helps ensure that we are assisting in the care of your patient in the best way possible. The below items are also required prior to scheduling the procedure and required for all referrals. They can be submitted by email, fax, or uploaded below.

    • Last 12 months of medical records
    • Last 12 months of lab results
    • Any diagnostic images and reports
    • Any other information you may find pertinent to the patient’s medical needs/concerns

    *rDVM must call prior to owner scheduling appointment and speak with a radiologist for outpatient CT

  • Drop files here or
  • Date Format: MM slash DD slash YYYY