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!

 

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:
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):