Outpatient Radiograph Referral
Clinic Name
*
Clinic Contact Information:
*
Clinic Phone
Clinic Email
Veterinarian Contact Information:
*
Veterinarian Name
Veterinarian Email
Client Contact Information:
*
Client Phone
Client Email
Client/Pet Information:
*
Client's Full Name
Pet's Name
Patient FAS Score
Please Select
1 - Relaxed
2
3
4
5 - Aggression
https://fearfreepets.com/fas-spectrum/
Clinical history / presenting complaint:
*
Please select the body region(s) to be x-rayed: Each region requested for diagnostic imaging will be billed as a separate charge.
*
Abdomen
Head
Neck
Thorax
Elbow
Shoulder
Tarsus
Carpus
Stifle
Pelvis
Metcheck
*Please indicate which side
Left
Right
Bilateral
Additional Notes for radiographic goals:
Precautions or concerns / ASA score:
*
ASA Reference: https://www.avtaa-vts.org/asa-ratings.pml
Current medications:
*
Relevant Records / X-Rays / Pre-Anesthetic Bloodwork
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Please select one of the following options regarding image review:
*
Send images to VSx's default radiologist for interpretation. Results will be forwarded once completed.
Send raw images directly to your practice without interpretation.
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