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.Format: 0000 0000.
Patient Information
Patient's Name
Patient Species and Breed
Gender
Weight
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.Format: 0000 0000.
CT Scan Information
Medical Notes
Scanning Site
Reporting Site
Turnaround Time
*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
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
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
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
Should be Empty:

CT Referral Form

Referring Clinic Information

Patient Information

Owners Information

CT Scan Information

Medical Notes

Scheduling

Patient History