CT Scan Referral Form
Referring Veterinarian Information
Hospital Name
*
Veterinarian's Name
*
Hospital Phone Number
Hospital Fax Number
Hospital Email
example@example.com
Client Information
First Name
*
Last Name
*
Phone Number
*
Email
example@example.com
Pet Information
Name
*
Species
*
Dog
Cat
Horse
Other
Sex
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Clinical Findings and Scan Request
Please summarize the patient's history and current clinical status that prompted the referral
*
Physical Exam Findings
*
Do you have a treatment plan for the current clinical signs?
Yes
No
Treatment pending imaging interpretation
Please indicate which study you would like performed from the lists below:
Please only choose one option
One-Study Submissions ($1100)
Brain
Skull/Head
Thorax
Abdomen
Cervical spine
Thoracic spine
Lumbar spine
Pelvis
Shoulders
Stifles
Elbows
Carpi or tarsi (including distal skeletal structures)
Two-Study Submissions ($1200)
Thorax and Abdomen
Brain and Cervical spine
Brain and Thoracic spine
Brain and Lumbar spine
Two-level spine (please specify below)
Brachial plexus
Lumbar plexus
Pelvis and Stifles
Should and Elbows
If you chose Two-level spine, please specify:
Three-Study Submissions ($1300)
Three-level spine collimated to the spine
Two-level spine without collimation
Lumbar spine, pelvis, and stifles
Cervical spine and full thoracic limbs
Four-Study Submissions ($1600)
Full spine without collimation
Any combination of four studies (please specify below)
Combination of four studies
What clinical question/concern you would like answered with this study?
Submit Form
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