Radiograph Referral Form

Referring Doctor's Name

First Name

Last Name

Referring Hospital

Hospital Email

Pet Owner Name

First Name

Last Name

Patient Name

Pet Owner's Email

Pet Owner's Phone Number

(###)

###

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Patient History

Do you have any specific questions or concerns for the radiologist?

We ask that all patients be provided with oral sedatives for this appointment.

I have provided my client with sedatives for this appointment.

My patient is not stable enough for sedation (please contact the hospital)

Report Timing:

A written report within two business days is sufficient for this case.

I need a same day report.

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

Our X-rays are performed by our trained technical team, and sent to our radiologist for remote interpretation. Reports are typically available within two business days. If you need an urgent report, please indicate so on the form.

Radiograph Referral Form

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