VICSD IMAGING REQUEST FORM
F: (858) 634-5435
F: (858) 256-7615
RDVM Information
Hospital Name
Referring
Veterinarian
Phone
Fax
Email
Patient Information
Owner Name
Patient Name
Species
Breed
Age      Weight   kg
Sex  Spayed or Neutered?   Yes   No
Patient History
Y N Y N
Patient Referral Options
  Fast-Track (Bill the Hospital) *     
Pet Taxi pick-up/drop off?    Yes   No 
*If this is a Fast-Track referral, a name is required of one of your office team members:: 


  Direct (Bill the Pet Owner)
Region of Interest
Abdomen Spine Skull/Head/Neck Musculoskeletal
Renal/Adrenal C1-C5 Brain Branchial Plexus
Liver C6-T2 Nasal Extremity:
IVP (Ectopic Ureter) T3-L3 Neck/Thyroid/Larynx
Cardiac L4-S2 Orbit
Thorax
Imaging Service Requested
Radiographs Nuclear Medicine (Circle Area of Study, if Applicable):
Bone Scan
Outpatient Ultrasound (at VICSD)
Front End  Hind End   Whole Body
Mobile Ultrasound (performed at your hospital)
Real Time Ultrasound (performed at your hospital) Portosystemic Shunt Imaging
Outpatient MRI Samples to be Collected at Time of Study
MRI Seizure Evaluation Package **Important: If Fast-Track Outpatient, please indicate your client pricing for sampling & analysis
Outpatient CT FNA               Abdominocentesis 
CT Rhinoscopy Package Urine               Thoracocentesis 
Other
Other (describe)             **If pricing is not indicated for sampling for Fast-Track clients, clients will be billed out directly by VICSD (on samples only)
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VETERINARY IMAGING CENTER OF SAN DIEGO
7522-7524 Clairemont Mesa Blvd I San Diego CA 92111 I P: (858) 634-5430 I F: (858) 634-5435 I www.vicsd.com