Imaging Request Form
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Hospital
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Doctor
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Hospital Phone Number
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Hospital Email
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Date of Scan Requested
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Time of Scan Requested
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Cavity
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Abdomen
Chest (Echo)
Double Cavity
Patient First and Last Name
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Species
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Sex
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Age
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Weight
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Breed
What did the patient present for? What are his/her symptoms?
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(V/D? E/D? Coughing?)
Exam findings and abnormal lab values
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(Exam Findings? Murmur? Bloodwork? Radiographs? Abnormal CBC/Chem values?)
Question you want answered with an ultrasound
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Comment or Message
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