Outpatient Imaging Referral Form

Clinic Phone Number*

Please provide the best number for the referring veterinarian - this should be a direct line to the DVM managing the case. We will contact them with case findings after the appointment.

Clinic Email Address

Please provide the most accurate email address for the report to be sent to. You can include multiple email addresses, separated by commas. Ensure correct spelling, as any errors may cause delays in receiving the final report.

What category does this patient fall under?*

Click here for descriptions/examples of each category. Please note that only patients in categories 1-3 will be seen by the outpatient imaging service. Critically ill patients may be referred to our Emergency & Critical Care service, and imaging will be performed as part of the clinical workup.

Temperament*

Extreme caution - aggressive or very likely to bite

Caution - May bite during procedures

Normal Precautions - Average Temperment

Patient is complete and total love bug

Other

Please indicate how recent imaging studies will be provided.*

Images will be sent via email

Images are accessible via link

Digital Images will come with client

Films will come with client

Images will be sent via postal mail

Primary Complaint*

Single sentence reason for referral. Further space is provided below for additional history.

Should we proceed with fine needle aspiration (FNA) if we find a lesion that is suitable for it? Have you already discussed the risks of FNA and sedation with the owner?*

Yes

We can perform ultrasound guided FNA in already sedated patients if our Emergency & Critical Care service is available to support, and only after our doctor has had the opportunity to call and consult with the referring veterinarian. If we’re unable to reach the referring veterinarian the FNA would need to be performed at a separate visit.

This patient has been examined recently and is sufficiently stable for abdominal ultrasound examination and relatively unsupervised ward stay for up to 8 hours*

Enter name of certifying veterinarian

This patient has been examined recently and is sufficiently stable for sedated computed tomography examination including the injection of iodinated contrast agent (commonly required for assessment of the thorax and abdomen, and for masses affecting the musculoskeletal system)*

Enter name of certifying veterinarian

Required Lab Work

Ultrasound examinations not requiring sedation, including pregnancy check or ultrasound of a musculoskeletal structure in an otherwise healthy animal, do not require bloodwork.

If imaging requires sedation, please click here to view information on required lab work. If required bloodwork is not included in the medical record, it will be performed in-house and charged to the client.

Patient Record Upload*

Records are required as part of the referral process. Please include any pertinent medical notes, lab results, imaging reports, etc. Email imaging to sa.reception@oregonstate.edu (DICOM strongly preferred). Please be aware that we do not have access to labs submitted to the Oregon Veterinary Diagnostic Lab (OVDL).

Drag and drop files here or

Contact Information

Oregon State University

Lois Bates Acheson Small Animal Veterinary Teaching Hospital

700 SW 30th Street

Corvallis, OR 97331

541-737-4812

https://vetmed.oregonstate.edu/hospital

Referring Veterinarian Information

Client Information

Patient Information

Imaging Modality

Required Lab Work

Contact Information