Radiograph Consultation Form

Radiograph Consultation Referral Form

MedVet Location(Required)

Today's Date(Required)

MedVet Cincinnati
3964 Red Bank Road
Cincinnati, OH 45227
Main: 513.561.0069
Fax: 513.808.4042
Email: referrals-cincinnati@medvet.com

MedVet Columbus
300 E. Wilson Bridge Road
Worthington, OH 43085
Main: 614.846.5800
Fax: 614.547.6689
Email: referrals.columbus@medvet.com

MedVet Dayton
2714 Springboro West
Moraine, OH 45439
Main: 937.293.2714
Fax: 937.293.2787
Email: appts.dayton@medvet.com

MedVet Indianapolis
9650 Mayflower Park Drive
Carmel, IN 46032
Main: 317.872.8387
Fax: 317.552.0919
Email: general.indy@medvet.com

MedVet New Orleans
2315 N Causeway Boulevard
Metairie, LA 70001
Main: 504.835.8508
Fax: 504.835.8509
Email: referrals.nola@medvet.com

MedVet Pittsburgh
2810 Washington Road
McMurray, PA 15317
Main: 724.717.2273
Fax: 724.638.8318
Email: info.pittsburgh@medvet.com

MedVet Toledo
2921 Douglas Road
Toledo, OH 43606
Main: 419.473.0328
Fax: 419.960.0503
Email: referrals.toledo@medvet.com

WestVet Boise
5024 W. Chinden Blvd.
Garden City, ID 83714
Main: 208.375.1600
Fax: 208.375.1606
Email: clientcare@westvet.net

Please Note: WestVet does not provide CTs or MRIs as outpatient services. Please prepare your patient for a consult with one of our specialists.

Your hospital will be invoiced for a radiology review and report fee.

Referring Clinic Information

Referring Veterinarian(Required)

Clinic / Practice Name(Required)

Phone(Required)

Fax

Email Address(Required)

Client & Patient Information

Client Name(Required)

First Last

Client Phone(Required)

Patient Name(Required)

Species(Required)

Canine

Feline

Other

Sex(Required)

Breed(Required)

Age(Required)

Color(Required)

Patient Weight

Patient Temperament

Radiographs Submitted?(Required)

Yes

Digital or Analog?

Digital, Sent to DICOM

Digital, on CD

Analog, Mailed

Analog, Sent with Owner

Digital or Analog?

Digital, Sent to DICOM

Digital, on CD

Digital, Attached to this Referral

Analog, Mailed

Analog, Sent with Owner

Study Information

Area of Interest(Required)

Study Date(s) & Number of Images(Required)

Referral Information

Reason for Referral / Primary Complaint(Required)

Clinical Exam / Pertinent Labwork Findings / Working Diagnosis(Required)

Specific Questions Regarding Radiographs

Upload Files

Drop files here or

Max. file size: 50 MB.

Accepted file types: jpg, gif, png, docx, pdf.

Final radiology consultation reports are typically available within one business day from the date they are received by the radiology department. If you are mailing analog images, please allow two-three additional business days for us to receive the images in the mail. Please contact our radiology office if there is urgency in receiving the results so that we may prioritize your consult. If you do not receive a report within the expected timeframe, please do not hesitate to contact the radiology office to ensure your consult has been received.

Refer a Patient

Radiograph Consultation Referral Form

Referring Clinic Information

Client & Patient Information

Study Information

Referral Information