Radiology Consultation Request Form

RDVM Information

Patient Information

Name:

Practice:

Address:

Phone:

Fax:

Email:

 

Patient Name:

Client Name:

Species:

Sex:

Male   Female

Neutered:

Yes   No

Breed:

Age:

Weight:

 

Radiographic Study

Abdomen

survey
adrenal/renal
liver
bladder-prost-ureth


Cervical - Soft Tissue

pharynx /larynx
thyroid


Cranium

skull
nasal
orbit
bulla

Extremity

Thoracic limb
    R   L

Pelvic limb
    R   L


Pelvis

Coxofemoral joints
Pelvis


Spine

Cervical
Thoracic
Lumbar

Thorax

lungs
brachial plexus
body wall
mediastinum


Special Studies

Esophagram
Upper GI
IVP
Urethrogram
Cystogram
Myelogram

 

Image Format

Method of Delivery

Date Sent

Film 
DICOM 
jpeg

 

Number of images sent:

Antech
IDEXX
DICOM Send
Fed Ex
US Mail
Web Upload (Choose this option if you are uploading digital images from our web site following submission of this form.)

 

Anesthesia / Sedation

None

Injectable (describe below:)

Inhalational (describe below:)

 

History / Clinical Signs / Laboratory / Previous Diagnostic Tests / Special Requests

 

(You will be able to upload digital images once you've submitted this form)