The Ohio State University     Veterinary Medical Center
Please schedule appointment (614.292.0950) prior to filling out this form. ** Completing this form DOES NOT schedule your appointment**
The information you provide below will help prepare the radiologist for the mobile visit and assist in creating a report in a timely manner.
Questions? See our FAQ sheet at https://vet.osu.edu/vmc/mobile
Clinic Name *
Your answer
Scheduled date of exam *
MM
/
DD
/
YYYY
Veterinarian *
Last name only
Your answer
Clinic Address *
Your answer
City/State/Zip *
Your answer
Phone *
(123) 456-7890
Your answer
Email address *
The report will be sent to the address below.
Your answer
Patient's Name *
Your answer
Owner's Last Name *
Your answer
Species *
Breed *
Your answer
Sex *
Age *
Please indicate years or months
Your answer
Patient's ID
Your answer
Type of Exam *
Required
History *
Your answer
Fine needle aspirates needed?
Please approve with owner prior to appointment
Comments or special considerations regarding appointment
Your answer
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