CT Scan Referral Form
Referring Veterinarian Information
In the event we have questions about the condition of the patient or need to discuss the scan request, it is very important that we are able to contact you, or an associate familiar with the case, during the procedure. A primary contact name must be included.
Hospital Name
*
Veterinarian's Name
*
Primary Contact Name
*
Primary Contact's 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
*
Any known medication reactions or issues with sedation/anesthesia?
*
Medications patient is currently prescribed.
*
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 ($1300)
Brain
Skull/Head
Thorax
Abdomen
Cervical spine
Thoracic spine
Lumbar spine
Pelvis
One Shoulder
One Stifle
One Elbow
One Carpi or tarsi (including distal skeletal structures)
Two-Study Submissions ($1400)
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
Both Shoulders
Both Stifles
Both Elbows
Both Carpi or Tarsi
If you chose Two-level spine, please specify:
Three-Study Submissions ($1500)
Three-level spine collimated to the spine
Two-level spine without collimation
Lumbar spine and pelvis
Cervical spine and full thoracic limbs
Four-Study Submissions ($1800)
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?
Lab Results
A CBC and Chemistry is required for all patients. These results can be emailed to animaleyeinstitute@gmail.com or faxed to 1-888-371-6068
Has a CBC and Chemistry been performed on the patient within the past 3 months?
*
Yes
No
Please upload CBC and Chemistry lab results performed within the last 3 months.
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Anesthetic Risk (ASA Status)
Performing a CT scan requires general anesthesia or heavy sedation. Although rare, there is a possibility of complications and inherent risks including, but not limited to abnormal reaction to sedation or contrast agents, heart, liver, and kidney failure, airway obstruction, aspiration, nerve damage, and death. Please assign an American Society of Anesthesiologists (ASA) Status to the patient using the following guidelines. This guideline will be used to determine appropriate anesthesia protocol for the patient.
ASA Classification
*
1: Excellent
2: Good
3: Fair
4: Poor
5: Guarded
Additional Info:
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