Outpatient Imaging Referral Form

Referring Doctor's Name

First Name

Last Name

Referring Hospital

Hospital Email

Service Requested

If requesting a focal ultrasound or radiographs, what is the area of interest?

Pet Owner Name

First Name

Last Name

Patient Name

Pet Owner's Email

Pet Owner's Phone Number

(###)

###

####

Medical history

Please list any current medications

Do you have any specific questions, concerns or goals for this appointment?

Sedation

In order to reduce patient stress and provide the best images possible, we ask that all patients receive sedatives one hour before their appointment time. (Suggested protocol Gabapentin 10-20mg/kg, Trazodone 5-10mg/kg). Day of procedure sedation through Remedy is available Monday to Thursday and will incur additional fees.

I have provided my patient with oral sedation and instructions on it's use.

I wish for Remedy to provide injectable sedation the day of the procedure.

I do not believe this patient can be safely sedated and I will contact Remedy to discuss.

Reports

We will send the report directly to your office, and do not provide interpretation services to the clients. Reports are returned within 2 business days. STAT reports are available in 1 business day, and often same day.

I would like the report with in two business days.

I need a STAT report.

Please note that this form is for a veterinarian or veterinary hospital to request radiology services for their patients. For our outpatient imaging services, referral to our hospital by your veterinarian is required.

Our ultrasounds and radiographs are performed by our trained technicians, and sent to our radiologist for remote interpretation. Reports are sent to the referring hospital within two business days. If you need an urgent report, please indicate so on the form.

Outpatient Imaging Referral Form

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