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Scintigraphy Referral Form
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Referring Veterinarian
Doctor Name
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Practice Name
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Practice Fax
Practice Email
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Client Information
Client Name
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Apartment/Unit
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Phone Number
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Patient Information
Patient Name
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Patient Date of Birth
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Breed
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Sex
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Stallion
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Patient Clinical History
Areas of main concern: (check required)
Scan Requested
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Brief clinical history about patient
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Have nerve or joint blocks been performed?
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Have recent radiographs been taken of this area?
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Are radiographs available for review if necessary?
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Radiographic findings
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