24-HR ER: 760-466-0600
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Our Services
Anesthesia and Pain Management
Blood Bank
Cardiology
Veterinary Dentistry
Dermatology
Diagnostic Imaging
Emergency/Critical Care
Internal Medicine
Interventional Radiology
Neurology
Oncology
Ophthalmology
Social Work
Surgery
Urgent Care by Ethos Near Here
For Your Pet
Client Registration Form
Emergencies + Appointments
Get in Line
When Your Pet is a Patient
Client Portal
Pet Insurance
Online Store
Prescription Refill Form
Grief Resources
Clinical Studies
For Veterinary Teams
Submit Referrals
Our Referral Process
At a Glance
Ethos Materials for Clinics
Continuing Education
Outpatient Imaging
Clinical Studies
VetBloom CE
About Us
Our Hospital
Our Team
Why Ethos
Veterinary Urgent Care by Ethos
Ethos Discovery
Contact Us
Blogs & Videos
Our Blogs
PAWEDcasts
We’re Hiring!
Apply Today
Job Fair Events
Benefits and Perks
Veterinary Training Programs
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
*
The sonographer will contact you at this number for discussion on the day of the scan
If you are not available to speak with the sonographer and client on the day of the scan, which in-office colleague should we contact?
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
Select files
Max. file size: 20 MB.
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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