Radiology Services Referral Referring Veterinarian's Name*Date* Date Format: MM slash DD slash YYYY Hospital Name*Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneFaxEmail Client Name First Last Home PhoneCell / OtherPatient's NameSpeciesBreedDate of BirthSexMaleFemaleAlteredYesNoMedical History / Physical Exam FindingsUltrasoundUltrasound Abdomen Outpatient US guided FNA Thyroid/Neck Portosystemic shunt Interpretation US guided palliative centesis Musculoskeletal Non-cardiac thorax Musculoskeletal - Body Part*CT/MRI InterpretationCT/MRI Interpretation Nasal/Head Cervical spine Thoracic spine Lumbar spine Thorax Abdomen Musculoskeletal Musculoskeletal - Body Part*RadiographsRadiographs Study by DVMS Interpretation Thorax 2 views 3 views Neck Esophagram Other Abdomen Survey Upper GI study Cystogram IV Pyelogram Other Interpretation - Number of views*Survey - Number of views*Thorax - Other*Abdomen - Other*Spine Cervical spine C/T spine Thoracic spine T/L spine Lumbar spine Lumbosacral spine Full spine Hindlimb Pelvis Femur Stifle Tibia Tarsus Hindpaw Forepaw Forelimb Scapula Shoulder Humerus Elbow Antebrachium Carpus Forepaw Orthopedic Left Right Nuclear MedicineNuclear Medicine GFR Scan Regional bone scan Whole body bone scan Thyroid scan Portosystemic shunt Regional bone scan - Body Part*ReportPlease send my report via Fax Email For patients referred directly to DVMS for radiograph studies or procedures, please read and initial the following: I have performed a complete physical exam and found this patient stable and healthy enough for sedation or anesthesia necessary to complete the requested studies. Animals at increased risk due to illness will be evaluated by a specialist at DVMS or at the Emergency Animal Clinic, LLP.Referring doctor's initialsAdditional Documents Drop files here or Please attach additional documents including medical records and original lab reports directly relating to this medical condition. Please send pertinent radiographs or other diagnostic images. Charges will be assessed on a standard per study basis. Please call our doctor if there is any immediate information you need to relay about this case. Thank you for the opportunity to participate in the treatment of this patient.