CT Referral Form

CT Referral Form
Referring Clinic Information
Referring Veterinary Clinic*
Referring Veterinarian*
Referring Clinic or Doctor Email*
example@example.com
CT Report Sent to Which Email
example@example.com
Referring Clinic Phone Number*
Please enter a valid phone number.
Patient Information
Patient's Name*
Patient Species and Breed*
Gender*

Male - IntactFemale - IntactMale - NeuteredFemale - SpayedUnknown
Weight*

< 20kg20-30kg30-40kg>40kg
Date of Birth (estimate if don't know)*
Owners Information
Owners Name*

First NameLast Name
Owners Email*
example@example.com
Owners Phone Number
Please enter a valid phone number.
CT Scan Information
Medical Notes
Scanning Site*

HeadNeckAbdomenThoraxShoulderElbowPelvisStifleFoot (Carpus or Tarsus)
Reporting Site*

HeadNeckAbdomenThoraxShoulderElbowPelvisStifleFoot (Carpus or Tarsus)
Turnaround Time*

Standard 7 Business DaysEnhanced - 2 Business Days*Priority - 24 Hours*Urgent - 4 Hours*
*VetCT charges an out-of-hours fee for cases submitted after 6pm on weekdays and from Friday 6pm to Monday 9am. This fee may be included if Urgent, Priority, or Enhanced turnaround is requested.
Contrast*

YesNo
Contrast is recommended for dogs and cats, especially when dealing with soft tissue.

For exotics, it varies from species to species.Please evaluate whether this patient is suitable for using contrast agent
Has Patient Had Previous CT Scan? If yes, please include information and report numbers in history

YesNoUnknown
History - this will be provided to VetCT for the radiologist. For best results, please provide a complete history.*
Questions To Ask Radiologist*
Other Important Information
Scheduling
Preferred Date
Preferred Time

ASAPMorningAfternoonEveningFirst Available
Patient History

Please attach any patient history files, or email history to info@hkvsi.com
Patient History

Cancelof
Imaging (X-rays, CT Scans,

Cancelof
Lab Tests and Bloodwork

Cancelof
Thank you for choosing out facility for your patient's CT scan, after we confimed the details about the CT request, we will contact the patient directly to schedule the appointment. The VETCT report will send to your email as provided.
Bill to*

Referring Veterinary ClinicOwner
Should be Empty:

CT Referral Form

Referring Clinic Information

Patient Information

Owners Information

CT Scan Information

Medical Notes

Scheduling

Patient History