Outpatient CT Referral Form

Outpatient CT Referral Form

If requesting an outpatient CT study, the requesting clinician will be solely responsible for communicating the results and making treatment recommendations based on the findings. If a consultation with a specialist is desired, then an appointment must be scheduled with a specialist instead of an outpatient CT.

Please complete the form below and upload or email the patients most recent 2 years of medical records, lab work and radiographs when applicable to [email protected]. After review of the submitted information, a CT technician will be in contact for scheduling. Please feel free to call us with any further questions.

CT Referral Form

Client name*
First Last
Address*
Street Address Street Address 2 City State / Province / Region ZIP / Postal Code Country
Home Phone*
Cell Phone
Alternate Phone
Email*
Pet Information
Pet name*
Species*
Breed*
Color*
Sex*
Date of birth/Age*
Weight (kg)*
Please indicate patient weight in kilograms.
Primary Veterinarian
Veterinary Clinic Name*
Primary Veterinarian Name*
Clinic Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Fax
Email*
Patient Case History
Reason for referral (chief complaint)*
Diagnostics and procedures*
Current Medications/Therapies*
Medical History/Clinical Signs*
Differential Diagnosis*
Region of Interest for CT scan*
- Head
- Neck
- Abdomen
- Thorax
- Spine
- Musculoskeletal
Other Region of Interest
Referral Type*
Please upload or email the patients most recent 2 years of medical records, lab work and radiographs when applicable to [email protected]
File upload
Max. file size: 100 MB.
Choose Files or drag here
Name
This field is for validation purposes and should be left unchanged.

OUTPATIENT CT REFERRAL FORM

Outpatient CT Referral Form

CT Referral Form

Pet Information

Primary Veterinarian

Patient Case History