CT Scan Referral Form

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*

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*
Any known medication reactions or issues with sedation/anesthesia?*
Current medications patient is currently prescribed.*
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 ($1300)

BrainSkull/HeadThoraxAbdomenCervical spineThoracic spineLumbar spinePelvisShouldersStiflesElbowsCarpi or tarsi (including distal skeletal structures)
Two-Study Submissions ($1400)

Thorax and AbdomenBrain and Cervical spineBrain and Thoracic spineBrain and Lumbar spineTwo-level spine (please specify below)Brachial plexusLumbar plexusPelvis and StiflesShoulders and Elbows
If you chose Two-level spine, please specify:
Three-Study Submissions ($1500)

Three-level spine collimated to the spineTwo-level spine without collimationLumbar spine, pelvis, and stiflesCervical spine and full thoracic limbs
Four-Study Submissions ($1800)

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?
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?*

YesNo
Please upload CBC and Chemistry lab results performed within the last 3 months.

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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:

Lab Results