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 AEIW 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 at 8:00 am the morning of their scan. Please be sure to click SUBMIT at the bottom of the form to submit your results.

Please also add our new email address to your list of contacts: advancedequineimaging@gmail.com.

Thank you for scheduling with Advanced Equine Imaging of Wellington.

Liz Redding

Advanced Equine Imaging of Wellington
MRI Technician
561-753-3226 office
315-569-7890 cell

Date of Appointment
MM
/
DD
/
YYYY
Referring Vet
Your answer
RDVM Email address
Your answer
RDVM 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
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
If you would prefer a specific imaging protocol to be performed, or additional imaging views, please specify here:
Your answer
Is there any further information regarding your patient that should be considered?
Your answer
AEIW pricing includes interpretation by board certified radiologist, Dr. Natasha Werpy DACVR DVM. If you would like interpretation by someone of your choosing please specify doctor and email address:
Your answer
Submit
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