Small Animal Nuclear Medicine Referral Form - Animal Imaging

Date of Submission*

Patient Name*

Patient Weight*

Breed*

Gender*

Age*

Owner's Name*

Phone*

Owner's Address*

Street Address City State ZIP Code

Owner's Email*

Other Authorized Party/Relationship

Phone

Referring Veterinarian*

Phone*

Referring Clinic*

Email Copy of Report to:*

Fax*

Please send any radiographs taken at your clinic for your client's appointment.

Radiographs:*

Sent through DVM insight
Emailed to info@animalimaging.net
Sent with client
None taken

Current Labwork?*

Yes (sent with referral)
No (please see requirements below)

Please check the exam you are prescribing for this patient. Please only request one area.*

Full Body Bone Scan
Front Half Bone Scan
Back Half Bone Scan
Thyroid Scan (required to determine eligibility for I-131 treatment) - Please include recent senior panel (including specific gravity) done within the last 30 days as it is needed for this procedure.
Portal Scan (transplenic) - Current Bile Acids, Chemistry & CBC with an adequate platelet count done within the last 30 days are required for this procedure
GFR Study

Specific Area of Interest:*

History and Reason for Exam:*

Symptoms:

Previous Surgery?*

Yes
No

Sedation OK if Needed?*

Yes
No

Any Known Drug Sensitivities?*

Yes
No

Please describe any known drug sensitivities*

Additional Exam You Are Prescribing:*

Please upload any relevant records, labs, and radiographs for this referral.

Drop files here or

Max. file size: 128 MB.

Veterinarian's Signature*

Veterinarian Certification*

I certify that I am a licensed veterinarian that has performed a physical examination on the aforementioned patient and am submitting this referral on their behalf.