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Diagnostic Imaging Procedure Request Form

Patients are admitted for their procedure at 8AM unless advised otherwise.
Patients should be fasted for more than 8 hours before procedures requiring anesthesia.
This completed form as well as a copy of recent laboratory evaluations
should accompany the patient for the procedure.

 

RDVM Information

Patient Information

Name:

Practice:

Address:

Phone:

Fax:

Email:

 

Patient Name:

Client Name:

Species:

Sex:

Male   Female

Neutered:

Yes   No

Breed:

Age:

Weight:

 

Computed Tomography

Abdomen

survey
adrenal/renal
liver
bladder-prost-ureth


Cervical-Soft Tissue

pharynx /larynx
thyroid

Cranium

brain
nasal
orbit
      R   L
bulla


Musculoskeletal Describe:

Spine
(neuroanatomic localization)

C1-5
C6-T2
T3-L3
L4-S2


Thorax

lungs
brachial plexus
body wall
mediastinum

 

Magnetic Resonance Imaging

Abdomen

survey
adrenal/renal
liver
bladder-prost-ureth


Cervical-Soft Tissue

pharynx /larynx
thyroid

Cranium

brain
nasal
orbit
      R L
bulla


Musculoskeletal Describe:

Spine
(neuroanatomic localization)

C1-5
C6-T2
T3-L3
L4-S2


Thorax

lungs
brachial plexus
body wall
mediastinum

 

Nuclear Medicine

Bone

metastasis screening

thoracic limb lameness

pelvic limb lameness

Cardiac (shunt evaluation)

Mucociliary Clearance

Lymphoscintigraphy

Portal (liver shunt evaluation)

Renal-Glomerular Filtration Rate

Thyroid
     I-131 therapy (if indicated)

Ventillation/Perfusion-Lung scan

 

Ultrasound
Abdominal

Cervical

Thoracic

 

Additional Requests
CSF Tap

Biopsy (list tissue below:)

Other (describe below:)

 

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