CT Request Form
Please ensure you fill in the required fields and attach the patient's full clinical history, any test results and images you have already acquired for this patient.
Client name
Prefix
First Name
Last Name
Address
Street Address
Street Address Line 2
City
County
Postcode
Email
example@example.com
Mobile number
-
Area Code
Phone Number
Alternative number
-
Area Code
Phone Number
Patient name
Patient details
Species
Breed
Age
Gender
Please Select
Male entire
Male neutered
Female entire
Female neutered
Does the client require an estimate? (If so, we can contact the clients directly)
Yes
No
Is the pet insured?
Yes
No
If yes, does the client want to do a direct claim?
Yes
No
Name of requesting Vet
First Name
Last Name
Practice name
Practice telephone number
-
Area Code
Phone Number
Email address to send the imaging report to
example@example.com
Body area(s) to be scanned (please tick all that apply)
Head and neck
Thorax
Abdomen
Forelimb series
Hindlimb series
Spine
Report turnaround time
Standard (1- 5 working days)
Urgent (24 hours)
Priority (4 hours)
Do you want an intravenous contrast study to be performed using omnipaque?
Yes
No
If YES, please tick if you want arterial, venous or soft tissue phases? (please tick all that apply)
Arterial (25 seconds)
Venous (45 seconds)
Soft tissue (2 minutes)
Unsure, please use contrast at the discretion of Claro Hill Vets
Do you want a CT myelogram or arthrogram? If yes, please call to discuss.
Yes
No
If YES, please specify:
Please provide a brief summary of the history for the VetOracle submission form:
Please attach the patient's clinical history. File upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Thank you!
Many thanks for completing the CT request form. We will be in touch with the clients as soon as possible to book them in for the CT and we will let you know once that appointment has been made. If you have any queries about the questions above, please do not hesitate to get in touch on 01423 228080.
Submit
Should be Empty: