Online Imaging Referral Form Online Imaging Referral for Veterinarians Please enable JavaScript in your browser to complete this form.Patient Name:Breed:Age:Multiple ChoiceMale, IntactMale, NeuteredFemale, IntactFemale, SpayedWeight:PLEASE SEND COPIES OF PERTINENT MEDICAL RECORDS, RADIOGRAPHS, AND LAB RESULTSReasons for Referral:Radiographs and/or images may be emailed or alternatively a direct DICOM transfer to our PACS. E-mail contact@vetheart.com to set up. No imagesDICOME-mailedVaccination Status:Canine DA2P:Date GivenFeline FVRCP:Date GivenRabies (1 yr, 3 yr, other)Date GivenMedical reason for precluding rabies vaccination (if any):Animal Temperament:Pertinent History:Please fax or email a copy of medical history pertaining to admitting complaint. Pertinent Lab Results:Please send a complete copy of results and reference intervals from any lab.No labsE-mailedFaxedCurrent Medication/ Treatment:If complex/ ongoing condition, please send medical records showing meds/ treatment.Previous anesthesia or surgery?YesNoComments:Is there any metal in this animal?Is the patient ambulatory?Referring Veterinarian: *FirstLastPractice Name *Address:Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone:Fax:E-mail: *General Information: General anesthesia is required for all CT examinations. Patients must arrive the morning of the scheduled procedure by 8:30am. The CT Request Form and Referral Form must all be received 48 hours prior to the appointment to facilitate safe anesthesia planning.SECTION I- Referring Veterinarian InformationPlease Note: It is very important that you or one of your associates is available by phone the day of the scan.SECTION II- CT Scan RequestedScan Region Requested:Pesumptive diagnosis/rule-outs:SECTION III- CT Report A written report will be sent via email or fax the next working day following the scan. Report preference:E-mailFaxE-mail:Fax:SECTION IV- Patient Information Refer to the instruction sheet to determine pre-anesthesia required laboratory tests based on ASA status, or call us for assistance. Please note that laboratory values should generally be no more than 2 weeks old.ASA Status (check one):1234*5**ASA 4 or 5 will require referral to IVSClient Name: *FirstLastClient E-mail: *Address:Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone 1:Phone 2:I agree to allow the Institute of Veterinary Specialists to place the report in its patient records for future use. Referring Veterinarian Name *FirstLastEmailSubmit
