Nuclear Scintigraphy Form

Nuclear Scintigraphy form

Date of Nuclear Scintigraphy Exam

Owner Name

Email Address

Horse Name

Breed *

Sex *

Male

Female

Age *

Color *

Address *

Address

City

State/Province

Zip/Postal

Country

Phone #1

Phone #2

Name on Credit Card

CVV / CCID (security code) *

Credit Card Number *

Expiration Date *

Were you referred by another veterinarian? *

Yes

If yes, please provide their name:

Share this info with that vet?

Yes

Note: It is a VEI policy to have credit card information prior to Nuclear Scintigraphy examination date. Your credit card will be debited at the end of the day that the horse was discharged, unless you prefer to pay by check in person at the time of the exam. By signing this information form, you authorize such a credit card debit (unless paid by check at the time payment is due).

Nuclear Scintigraphy Exam Costs: • Whole Body: $2195.00 • Front or hind End: $1835.00 The items below are included in the total fee. • Office call • Hospitalization • Sedation • Isotope • Nuclear Scintigraphy Imaging and Report

Additional Imaging/diagnostics/treatment plans will be billed separately. *

I agree

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