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Resources
for Clients
Diagnostic Imaging
Hyperthyroidism
AVMI Anniversary Club
Letters
AVMI Success Stories
for Referring Veterinarians
Diagnostic Imaging
Radioiodine Therapy
Feline Hyperthyroidism
Sending Images
Services
Radiotherapy
Brachytherapy
Canine Thyroid Carcinoma
Feline Hyperthyroidism
Scintigraphy
Bone Scintigraphy
Portal Scintigraphy
Renal Scintigraphy
Thyroid Scintigraphy
MRI
CT
Information
AVMI News
CT Concepts
Downloads
Hyperthyroid Hints
Imaging Diagnosis
Scintigraphy Selections
Thyroid Thoughts
Videos
Contact
Contact Us
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Diagnostic Imaging Procedure Request Form
Asterisks indicate required fields.
Once you have selected the modality you will be able to click the
Submit
button at the bottom of the form.
Name of person completing this form
*
RDVM Information
RDVM Name
*
Practice
*
Address
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Armed Forces Americas
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State
ZIP Code
Phone
*
Fax
*
Email
Patient Information
Patient Name
*
Client Name
*
Species
*
Canine
Feline
Other
Sex
*
Male
Female
Neutered
*
Yes
No
Breed
*
Age (years)
*
Weight (lbs.)
*
Modality (Please select from the modality list below to complete the request form.)
Need help determining the best modality to evaluate your patient's problem?
Check out our
Imaging Modality Worksheet
Modality
*
Computed Tomography
Magnetic Resonance Imaging
Nuclear Medicine
Radionuclide Therapy
Ultrasound
Additional Requests
Computed Tomography
Abdomen
survey
adrenal/renal
liver
blader-prostate-urethra
Cervical Soft Tissues
pharynx/larynx
thyroid
Cranium
brain
nasal
orbit
bulla
Spine (neuroanatomic localization)
C1-T2
T3-L3
L4-S2
Thorax
lungs
brachial plexus
body wall
mediastinum
Musculoskeletal (describe)
Magnetic Resonance Imaging
Abdomen
survey
adrenal/renal
liver
blader-prostate-urethra
Cervical Soft Tissues
pharynx/larynx
thyroid
Cranium
brain
nasal
orbit
bulla
Spine (neuroanatomic localization)
C1-T2
T3-L3
L4-S2
Thorax
lungs
brachial plexus
body wall
mediastinum
Musculoskeletal (describe)
Nuclear Medicine (scintigraphy)
Bone
metastasis screen
thoracic limb lameness
pelvic limb lameness
Cardiac
Cardiac (shunt evaluation)
Mucociliary Clearance
Mucociliary Clearance
Lymphoscintigraphy
Lymphoscintigraphy
Portal
Portal (liver shunt evaluation)
Renal
Renal - Glomerular Filtration Rate
Thyroid
Thyroid
Ventilation/Perfusion
Ventilation/Perfusion - Lung Scan
Radionuclide Therapy
Radionuclide Therapy
Radioiodine (I-131)
Samarium (EDTMP Sm-153)
Ultrasound
Body region
abdominal
cervical
thoracic
Additional Requests
CSF tap
Biopsy
Other (describe)
History / Clinical Signs / Laboratory / Special Requests
History / Clinical Signs / Laboratory / Special Requests
*
Phone
This field is for validation purposes and should be left unchanged.
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