Teleradiology Request Form
Welcome to our Teleradiology Request Form! Before proceeding to make a request, please check the box below to signify your understanding and agreement. By checking this box, you acknowledge that you are requesting a teleradiology consultation and report from Dr. Tibbs, our board-certified radiologist. Please be aware that your clinic will be invoiced for the teleradiology consultation fee upon submission.
I Understand
If you have made arrangements for another DCES doctor to provide a non-radiologist review, please DO NOT check the box above, and indicate which DCES doctor needs these images forwarded to them below. Please call the office at 301-809-8800 if you have any additional questions.
Teleradiology Request Form
Referring Information
Date
*
-
Month
-
Day
Year
Date
Doctor
*
First Name
Last Name
Hospital Name
*
Phone Number
*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
E-Mail
*
Client & Patient Information
Client Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Patient Name
*
Patient Date of Birth
-
Month
-
Day
Year
Date
If you do not know exact birthday, please provide how many months or years your pet is.
Species
*
Dog
Cat
Breed
Sex
*
Male
Female
Male Neutered
Female Spayed
How many images are you submitting?
*
Additional Information
Reason For Visit
*
Body Area / Views Submitted
*
Current Treatment & Medications
*
Additional Comments
Submit
Should be Empty: