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:

To send DICOM images directly to Auburn:

From (referring veterinarian's e-mail) *
Subject
Preferred Radiologist *	First Available Almond Cole Brawner Hathcock Holland
Preferred Report Type: *	E-mail Fax Letter
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 *	Fe Fe/S Male Male/N
Age *
Images Submitted: *	Radiographs CT MRI NM Radiation Therapy Consultation
Case History / Clinical Signs
Specific questions regarding this case/imaging study:
Which method of image submission do you intend to use?	I will send original DICOM images directly to Auburn's server. I will mail in film or CD-ROM Other (describe below) If images are to be sent digitally, original DICOM images are preferred.
If "other" was selected above, describe here:	Original DICOM images are preferred.