University of Minnesota
University of Minnesota - Veterinary Medical Center
http://www.vmcinfo.umn.edu/

Small Animal Referral Form

Form Fields Marked with an Asterisk * are Required
Have you called the VMC about this referral?
Referral Information
Client Information
* Requested Service
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Outpatient Medical Imaging:
For outpatient medical imaging, please see our AVID page: Go to VMC - AVID
Animal Information
 
 
 
 
 
* Visit Timeframe
 
 
Visit Information
Procedures Already Performed
Labs:
Please Indicate which labs have been completed, labs should be sent in with the owner or via fax.
 
 
 
 
 
 
Imaging:
Please indicate imaging that has been completed. Imaging may be sent in with the owner, via email, or to our DICOM server.
 
 
Fax Number (For Labs):    612 - 624 - 8779

Email Address (For Imaging):    vetpacs@umn.edu
 
DICOM Server:
IP Address/Hostname: 134.84.120.106
AE Title: D6541
Port Number: 4006
Please indicate if DICOM images will be sent to our server.
Who should receive an email copy of this referral?
 
Please Note, If you elect to send an email copy to your client they will not recieve the visit information or information about procedures already performed.
Please Note: Some services may request additional information.