CASE READ SUBMISSION FORM
F: (858) 634-5435
RDVM Information
Hospital Name
Referring
Veterinarian
Phone
Fax
Email
Patient Information
Owner Name
Patient Name
Species
Breed
Age
Years
Months
Weight
lbs
Sex
Male
Female
Spayed or Neutered?
Y
N
Date of Examination
Number of Views submitted for Review
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
more than 15 OMG
CT/MRI
Prior images on VPACS
Yes
No
Patient History and Specific Questions You Would Like Answered
Case Read Options - Online DICOM Viewer can be found at www.vicsd.com/VPACS
STAT INTERPRETATION $27 in addition to review fee
Radiograph Review - Film @ $57
Radiograph Review - Digital @ $57
CT/MRI Review - Digital @ $94
Contrast Series @ $80
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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