Nuc Scan Referral Form
Hello,

Below is the history form for your patient's Nuclear Scintigraphy exam. Please complete the history form to the best of your knowledge and send back to BW Furlong & Associates 24 hours prior to your client's appointment. If you would like to speak to Dr. Gold further regarding this appointment, she can be reached at 908-625-6623 or sgold@bwfurlong.com. We ask that horses arrive between 7:45 and 8:00 am the morning of their scan.

Thank you for scheduling with BW Furlong & Associates!

Date of Appointment *
MM
/
DD
/
YYYY
Referring Vet *
Your answer
RDVM Email address *
Your answer
Contact Phone *
Your answer
Owner Name *
Your answer
Owner/Trainer Contact Number *
for pick-up and billing
Your answer
Horse Information
Horse Name *
Your answer
Sex
Date Of Birth
Your answer
Breed
Your answer
Horse's Occupation & Level
Your answer
Requested Study *
Your answer
Solar Views *
if yes, please, shoes will be removed
Soft Tissue Phase *
If doing a soft tissue phase, please specify one area
please be specific, e.g. Left Hock
Your answer
Lunge
Soundness History
Affected Limb *
Required
Please describe the nature of the lameness, including duration and Grade: *
Your answer
Please describe the blocking pattern (nerve, joint, bursal blocks): *
Your answer
Previous diagnostic imaging results (radiographs, ultrasound, nuclear scintigraphy, MRIs):
Your answer
Is there any further information regarding your patient that should be considered?
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of B.W. Furlong & Associates. Report Abuse - Terms of Service