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904-417-8589
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Home
About Us
- Testimonials
Our Services
Referring Vets
- Radiology Referrals
  - Imaging Submission Form
  - Ultrasound, Echocardiogram Submission Form
Patient Center

Home
About Us
- Testimonials
Our Services
Referring Vets
- Radiology Referrals
  - Imaging Submission Form
  - Ultrasound, Echocardiogram Submission Form
Patient Center

904-417-8589
Get Directions
Contact Us
Request Appointment

Veterinary Imaging Referrals Radiographs, CT, Imaging Submission Form

Veterinary Clinic*
Referral Information
Referring Veterinarian*
Phone Number*
Email*
Patient Information
Patient Name*
Owner Name*
Phone Number*
Email*
Pet Information
Pet's Name
Breed (If known)
Age:
Weight (lbs)
Sex
- Female Intact
- Female Spayed
- Male Intact
- Male Neutered
Select study
- Radiograph Interpretation (Teleradiology)
- Outpatient radiographs with radiologist Interpretation
- Outpatient radiographs without radiologist Interpretation
- Fluoroscopy
- Outpatient Computed Tomography (CT scan) with radiologist Interpretation
- Outpatient Computed Tomography (CT scan) without radiologist Interpretation
Pet Medical History
Pertinent History (main clinical complaint)
Physical Exam (abnormalities)
Laboratory Abnormalities (please provide labwork per email or portal upload)
Radiographs available (please provide radiographs as DICOM images per email or direct DICOM transfer)
- Yes
- No
Current Medications (medication with dosage)
Any known contraindication for sedation or anesthesia
- Butorphanol (0.2-0.4 mg/kg)
- Dexmedetomidine 2-4 micrograms/kg (not for cardiac patients)
- Midazolam/Diazepam
- Alfaxolone
- Propofol
- Isoflurane
- Others (please specify reason for contraindication)
Additional Comments/Requests

27033

Contact Info

135-1 Cumberland Park Dr
St. Augustine, FL 32095

Phone: 904-417-8589
Email: Info@ecovetsfl.com

Office Hours

Specialty Hospital:
Monday-Friday: 8am-6pm

Emergency Room Temporary Hours:
Monday-Sunday 8am-10pm

24/7 Emergency Care Starting May 5th

Contact Info

135-1 Cumberland Park Dr
St. Augustine, FL 32095

Phone: 904-417-8589

Office Hours

Specialty Hospital:
Monday-Friday: 8am-6pm

Emergency Room Temporary Hours:
Monday-Sunday 8am-10pm

24/7 Emergency Care Starting May 5th

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