Diagnostic Imaging Procedure Request Form

Asterisks indicate required fields.
Once you have selected the modality you will be able to click the Submit button at the bottom of the form.

Name of person completing this form*
RDVM Information
RDVM Name*
Practice*
Address
Street Address City State ZIP Code
Phone*
Fax*
Email
Patient Information
Patient Name*
Client Name*
Species*
Sex*
Neutered*
Breed*
Age (years)*
Weight (lbs.)*
Modality (Please select from the modality list below to complete the request form.)
Need help determining the best modality to evaluate your patient's problem?

Check out our Imaging Modality Worksheet
Modality*
- Computed Tomography
- Magnetic Resonance Imaging
- Nuclear Medicine
- Radionuclide Therapy
- Ultrasound
- Additional Requests
Computed Tomography
Abdomen
- survey
- adrenal/renal
- liver
- blader-prostate-urethra
Cervical Soft Tissues
- pharynx/larynx
- thyroid
Cranium
- brain
- nasal
- orbit
- bulla
Spine (neuroanatomic localization)
- C1-T2
- T3-L3
- L4-S2
Thorax
- lungs
- brachial plexus
- body wall
- mediastinum
Musculoskeletal (describe)
Magnetic Resonance Imaging
Abdomen
- survey
- adrenal/renal
- liver
- blader-prostate-urethra
Cervical Soft Tissues
- pharynx/larynx
- thyroid
Cranium
- brain
- nasal
- orbit
- bulla
Spine (neuroanatomic localization)
- C1-T2
- T3-L3
- L4-S2
Thorax
- lungs
- brachial plexus
- body wall
- mediastinum
Musculoskeletal (describe)
Nuclear Medicine (scintigraphy)
Bone
- metastasis screen
- thoracic limb lameness
- pelvic limb lameness
Cardiac
- Cardiac (shunt evaluation)
Mucociliary Clearance
- Mucociliary Clearance
Lymphoscintigraphy
- Lymphoscintigraphy
Portal
- Portal (liver shunt evaluation)
Renal
- Renal - Glomerular Filtration Rate
Thyroid
- Thyroid
Ventilation/Perfusion
- Ventilation/Perfusion - Lung Scan
Radionuclide Therapy
Radionuclide Therapy
- Radioiodine (I-131)
- Samarium (EDTMP Sm-153)
Ultrasound
Body region
- abdominal
- cervical
- thoracic
Additional Requests
- CSF tap
- Biopsy
Other (describe)
History / Clinical Signs / Laboratory / Special Requests
History / Clinical Signs / Laboratory / Special Requests*
Comments
This field is for validation purposes and should be left unchanged.

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Diagnostic Imaging Procedure Request Form

RDVM Information

Patient Information

Modality (Please select from the modality list below to complete the request form.)

Computed Tomography

Magnetic Resonance Imaging

Nuclear Medicine (scintigraphy)

Radionuclide Therapy

Ultrasound

Additional Requests

History / Clinical Signs / Laboratory / Special Requests