Online Diagnostic Imaging Referral Form

Please send any digital images in DICOM format (not JPG). You may transmit DICOM files via your PACS server directly to SFVS's PACS server. For help with PACS connectivity, please contact Tommy Meers at 404-924-2000, ext. 108. Please ensure that all images include patient name and hospital name. Diskettes will not be returned, so please retain copies of all images for your records. Thank you!

* Required

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Date *

DVM Name *

Hospital Name *

DVM Phone*

DVM Fax

DVM Email *

Has Patient Visited SFVS Previously? *
Yes No

Pet Owner Name *

Pet Name *

Pet Age
*

Pet Gender *
Female Male

Neutered / Spayed Intact

Pet Weight *

Pet Breed *

Brief History *

Area Imaged and Date Taken *

Chief Complaint or Working Diagnosis *

Physical Findings and Diagnostic Tests Performed *

Treatments For Current Problem *

Special Imaging Requests

Specific Questions About Films Being Sent

Radiographs *
FILMS: referring DVM sending films to SFVS
DIGITAL: Images being sent on disk
DIGITAL: Dicom images will be sent via online server connection

Vetpacs Code (if any)

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Online Diagnostic Imaging Referral Form