CT Referral Form

REFERRING VETERINARIAN INFORMATION

Referring Veterinarian*

Referring Clinic*

Referring Clinic Email*

We will use this to send you a confirmation copy of this form.

Referring Clinic Phone Number

PATIENT INFORMATION

Name of Patient

Sex of Patient*

Spayed Female

Neutered Male

Intact Female

Intact Male

Patient Date of Birth, or Age (in years)

Species*

Canine

Feline

Other

Breed

Weight

PATIENT MEDICAL INFORMATION

Area of Scan*

Should we call client to schedule?

Yes

Other Comments/ Suspected Problem

Type of Appointment Needed

Were X-rays taken?

Yes

Date and results of last Chemistry / CBC panel - must be within 1 week of scan-please forward for DVM Review

Medical History

Describe symptoms, signs, onset, progression, etc.

REFERRING VETERINARIAN INFORMATION

Referring Veterinarian*

Referring Clinic*

Referring Clinic Email*

Referring Clinic Phone Number

PATIENT INFORMATION

Name of Patient

Sex of Patient*

Patient Date of Birth, or Age (in years)

Species*

Breed

Weight

PATIENT MEDICAL INFORMATION

Area of Scan*

Should we call client to schedule?

Other Comments/ Suspected Problem

Type of Appointment Needed

Were X-rays taken?

Date and results of last Chemistry / CBC panel - must be within 1 week of scan-please forward for DVM Review

Medical History

Diagnostics

Case Summary/Comment

What specific goal or piece of information do you hope to gain from this study?