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
Select One
Years
Months
Weight
kg
Sex
Spayed or Neutered?
Yes
No
Patient History
IMPORTANT:
Previous U/S done by VICSD
Y
N
Radiographs performed
Y
N
Patient Referral Options
Fast-Track (Bill the Hospital) *
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
Samples to be Collected at Time of Study
**Important:
If Fast-Track Outpatient, please indicate your client pricing for sampling & analysis
Outpatient CT
FNA
Abdominocentesis
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
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