Oklahoma State University


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    (revised September, 2010)
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    Radiology Service
    142-A VMTH
    Stillwater, OK 74078-2041
    (405) 744-7000
    * - Required Field
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    Referring DVM Information
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    Doctor: *
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    Hospital Name: *
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    Street Address: *
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    City *
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    State *
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    Zip Code *
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    Telephone #: *
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    Fax #:
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    Email (report will be sent electronically:
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    Patient Information
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    Owner Name: *
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    Animal Name: *
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    Breed: *
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    Sex/Neutered: *
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    Age: *
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    Consultation Options
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    Paying by check (please make checks payable to Oklahoma State University)
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    Paying by credit card (DO NOT include your credit card number on the form. A member of the OSU staff will contact you to obtain it.)
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    RAD/US - $54.50
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    CT/MRI/Pre-purchase exam - $100.00
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    Please provide brief history, physical examination findings and pertinent laboratory findings *
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    Mail films or electronic images on CD to address above.
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