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Animal Imaging – Veterinary Radiology
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Animal Imaging – Veterinary Radiology
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Equine Ultrasound
Equine Radiograph
Equine MRI
Equine Nuclear Medicine
Please fill out the form below as completely as possible and someone will be in touch with you shortly. If you would prefer to fax or email in a PDF feel free to download one by clicking the button below.
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Equine CT Referral
Registered Name
Barn Name
Breed
Gender
Stallion
Gelding
Mare
Age
Color
Owner's Name
Owner's Phone
Owner's Email
Main Contact (if different than owner)
Main Contact Phone
Main Contact Email
Referring Veterinarian
Veterinarian Contact Phone
Clinic Name
Email Copy of Report to
Fax
Please send any radiographs taken at your clinic for your client's appointment.
Radiographs:
Sent through DVM insight
Emailed to info@animalimaging.net
Sent with client
None taken
Please check exam your prescribing to this patient.
CT of Skull / Sinuses
CT - Foal
Contrast (if indicated)
Yes
No
Specific Area of Interest
Symptoms/Clinical Signs
Additional Exam You Are Prescribing?
Please upload any relevant records, labs, and radiographs for this referral.
Drop files here or
Veterinarian's Signature
Veterinarian Certification
*
I certify that I am a licensed veterinarian that has performed a physical examination on the aforementioned patient and am submitting this referral on their behalf.
Phone
This field is for validation purposes and should be left unchanged.
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logo-Animal Imaging
Animal Imaging – Veterinary Radiology
Your Veterinary Imaging Specialists
About Us
Our Vets
Our Team
Case Studies
Learning Center
Sign-Up For CE Events
Imaging Services
Equine
Small Animal
Refer A Patient
Small Animal Referral Forms
Equine Referral Forms
Contact Us
Call Now
Get Directions