Veterinary Teaching Hospital
Equine Outpatient Imaging Service
4700 Hillsborough Street
Raleigh, NC 27606
NC STATE UNIVERSITY
COLLEGE OF VETERINARY MEDICINE
Michael Schramme, DVM, CertEO, PhD, DipECVS
Orthopedic Surgeon
Director, Equine Outpatient Imaging Service
cvm_eqoprads@ncsu.edu
Appointments:
FAX:
Radiology Service:
919.513.6006
919.513.6717
919.513.6590
BONE SCAN ORDER SHEET
Patient Name: ___________________________________
Veterinarian: ____________________________
Client: __________________________________________
VASCULAR AND SOFT TISSUE PHASE (Pick One only):



Distal Forelimb (below knee)
Distal Hindlimb (below hock)
Other (contact Dr. Schramme)
If the horse is particularly large, it may not be possible to image both the feet and proximal suspensory
region with the time constraints of the soft tissue phase. Please indicate which region is of greatest
importance to image for this particular case:


Feet
Proximal suspensory
BONE PHASE (Pick as many as needed):








Forelimb (Including scapula)
Hindlimb (Including hip)
Pelvis
Head
Neck
Thoracic Spine
Lumbar Spine
Focal only (Contact Dr. Schramme)
Verbal Report needed?
Yes
Final Report needed? Yes
No
No