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Radiology Referral Form

Please complete the online referral form below. Instructions for submission of film, CD-ROM or DICOM images is as follows: 

Address to mail in films or CDs:

  • Bailey Small Animal Teaching Hospital
  • Attn: Radiology
  • Auburn University
  • 1220 Wire Road 
  • Auburn, AL 36849-5540 

To send DICOM images directly to Auburn:

  • AE Title: rad-offsite (note this is case sensitive) 
  • Hostname (IP address): 131.204.152.86 
  • Port: 4006
From (referring veterinarian's e-mail) *
Subject
Preferred Radiologist *







Preferred Report Type: *
      

Original Date of Study *
Referring Veterinarian *
Clinic Name *
Street Address *
City, State and Zip *
Referring Veterinarian's Phone *
Referring Veterinarian Fax *
Client's Name *
Animal Name *
Species *
Breed *
Sex *
        

Age *
Images Submitted: *






Case History / Clinical Signs

Specific questions regarding this case/imaging study:

Which method of image submission do you intend to use?




If images are to be sent digitally, original DICOM images are preferred.
If "other" was selected above, describe here:

Original DICOM images are preferred.
© 2009 Auburn University College of Veterinary Medicine