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Our Services
Blood Bank
Cardiology
Veterinary Dentistry
Dermatology
Diagnostic Imaging
Emergency/Critical Care
Internal Medicine
Interventional Radiology
Neurology
Oncology
Physical Rehabilitation
Sports Medicine & Rehabilitation
Surgery
For Your Pet
Client Registration Form
When Your Pet is a Patient
Client Portal
Pet Insurance
Online Store
Prescription Refill Form
Grief Resources
Clinical Studies
For Veterinary Teams
Our Referral Process
Referral Forms and Portal
COVID-19 Hospital Updates
Continuing Education
Outpatient Imaging
Clinical Studies
VetBloom
Contact Us
About Us
Our Hospital
Our Team
Why Ethos
Contact Us
Our Blogs
We’re Hiring!
Apply Today
Job Fair Events
Benefits and Perks
Vet Student Externships
Candidate Competencies
Continuing Education
24-HR ER: 760-466-0600
760-466-0600
Outpatient Imaging Request
Referring Veterinarian Information
This form is to be completed by the referring veterinary hospital.
Referring Doctor Name
*
Referring Hospital
*
Referring Veterinarian Email
We will send a confirmation to this email address
Referring Veterinarian Phone
*
Referring Veterinarian Fax
Client Information
Client Name
*
Client Phone
*
Patient Information
Patient Name
*
Patient Date of Birth
*
Species
Dog
Cat
Breed
*
Patient Sex
Spayed Female
Neutered Male
Intact Female
Intact Male
Clinical Information
Clinical Questions to Answer
*
Patient Medical History/Problem List
*
Medical Conditions that Complicate Sedation or Anesthesia
*
Current Medications/Treatment
*
Attach pertinent records, labwork, or pathology results
Drop files here or
The patient will only receive imaging during their appointment. If an examination or workup is needed, a referral can be arranged, but ONLY at your direction. If the patient is deemed unstable by the Radiologist at check-in, we will contact you immediately.
Comments
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