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IMAGING REQUEST & REFERRAL FORM

    Referring Entity Clinic Name Referring Veterinarian
    Clinic Phone*
    Email Address* Owner & Patient Information
    Owner First Name*
    Phone*
    Patient Name*
    Weight*
    Breed*
    Additional Patient Information Patient History
    Ultrasound Do you recommend sedation based on patient history?

    Assessment Information

    For a complete assessment, please send any recently performed imaging including radiographs with the patient regardless of desire for radiographic consultation. For CT imaging with contrast please include recent (within 6 months) blood work including renal profile. Preliminary ultrasound results may be available the same day and radiology consultation for both ultrasound and CT are typically available within 24-48 hours.


    Attachments
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    Collin County Veterinary Imaging Center / 5353 Independence Pkwy. Ste. 100 / Frisco, TX 75035
    P: (469)795-9142 F: (469)795-9143 / Email: info@ccvic.us / Website: www.ccvic.us