CT Scan Referral Form

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*

DogCatHorseOther
Sex*

MaleFemale
Date of Birth*

MonthDayYear
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?

YesNoTreatment pending imaging interpretation
Please indicate which study you would like performed from the lists below:

Please only choose one option
One-Study Submissions ($1100)

BrainSkull/HeadThoraxAbdomenCervical spineThoracic spineLumbar spinePelvisShouldersStiflesElbowsCarpi or tarsi (including distal skeletal structures)
Two-Study Submissions ($1200)

Thorax and AbdomenBrain and Cervical spineBrain and Thoracic spineBrain and Lumbar spineTwo-level spine (please specify below)Brachial plexusLumbar plexusPelvis and StiflesShould and Elbows
If you chose Two-level spine, please specify:
Three-Study Submissions ($1300)

Three-level spine collimated to the spineTwo-level spine without collimationLumbar spine, pelvis, and stiflesCervical spine and full thoracic limbs
Four-Study Submissions ($1600)

Full spine without collimationAny combination of four studies (please specify below)
Combination of four studies
What clinical question/concern you would like answered with this study?
Should be Empty:

CT Scan Referral Form

Referring Veterinarian Information

Client Information

Pet Information

Clinical Findings and Scan Request

Please indicate which study you would like performed from the lists below: