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.
Primary Contact Name
Primary Contact's Phone Number
Hospital Fax Number
Date of Birth
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?
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)
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)
Pelvis and Stifles
Shoulders and Elbows
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, pelvis, and stifles
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?
Should be Empty: