VICSD IMAGING REQUEST FORM
F: (858) 634-5435
RDVM Information
Hospital Name
Referring
Veterinarian
Phone
Fax
Email
Patient Information
Owner Name The radiologist has the permission to consult with the client Y N
Patient Name
Species
Breed
Age      Weight    lbs
Sex   Spayed or Neutered? Spayed  Neutered
Patient History
Patient Referral Options
 Fast-Track *
 *If this is a Fast-Track referral, please enter the authorizer's name:
 Direct
Pet Taxi pick-up/drop off?  Yes  No
Imaging Service Requested
Nuclear Medicine (Circle Area of Study, if Applicable):
Radiographs Bone Scan
Front End  Hind End   Whole Body
Radiograph Review           STAT Bone Scan with Orthopedic
Front End  Hind End   Whole Body
Outpatient Ultrasound (at VICSD) Portosystemic Shunt Imaging
(Colonic Scintigraphy or Nuclear Splenoportogram)
Mobile Ultrasound (at your hospital) Portosystemic Shunt Evaluation Package
(Nuclear Shunt Study and CT)
Outpatient MRI Thyroid Scan
MRI Seizure Evaluation Package Glomerular Filtration Rate Study (GFR)
Outpatient CT Portal Scan
CT Rhinoscopy Package Ciliary Function Study
CT Thorax Metastatic Evaluation Package Osteosarcoma Screening Package
Other (describe)            
Region of Interest
Abdomen Spine Skull/Head/Neck Musculoskeletal
C1-C5 Brain
Cardiac C6-T2 Nasal
T3-L3 Neck/Thyroid/Larynx Other 
Thorax L4-S2 Orbit  
Samples to be Collected at Time of Study
Blood CSF Abdominocentesis
If Fast-Track, please indicate your client pricing for sampling & analysis :
Urine FNA Thoracocentesis
Other
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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