CT Referral Form

Out-Patient CT Referral Form

Questions? Please call 804-348-8808 or e-mail info@oasisvetrva.com.
Referring DVM Information
Clinic Name*
Referring Veterinarian*

First NameLast Name
Phone Number*
Email*
Patient Information
Client Name*

First NameLast Name
Client Phone Number*
Client Email*
Patient Name*
Date of Birth / Age
Species*
Breed and Color
Sex*
Weight*
Current on Vaccinations:

RabiesDA2PPBordetellaFecal
Spayed / Neutered?*
Each patient should have a physical exam, CBC, and chemistry panel prior to the CT exam to evaluate anesthetic and contrast risk. CBC/chem panels NOT REQUIRED for very small exotic species. Please send lab results with this order if available.

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Working diagnosis and reason for exam: *
Please include a brief clinical summary of patient history, pertinent clinical findings and treatments. This information will be sent to the radiologist and included in the radiology report.
Please check the exam(s) you are prescribing for this patient:*

CT of Skull / Nasal PassageCT of SpineCT of ThoraxCT of Forelimbs / ShoulderCT of AbdomenCT of Hindlimbs / HipsFluoroscopyOther
Please note the specific area of interest. For example, "T-L Spine": *
STAT radiology read request (guaranteed report within 24 hours, typically less than 6)
Client Communication: Outpatient CT pets will be received by a doctor who will perform a general preanesthetic examination prior to the CT procedure. CT pets will be returned to their owner after recovery from the procedure. The client will be given a thumb drive containg the DICOM image set for the referring veterinarian's review. A formal CT report (by a board-certified radiologist) will be e-mailed to the referring veterinarian within 48 hours. Please inform the client that CT findings and any additional treatment plans will be discussed with them by the referring veterinarian.
Potential Risk of Anesthesia: If a patient is anesthetized, a fully qualified technician working under the direct supervision of a veterinarian will be with the animal throughout the anesthesia and initial recovery period. In spite of stringent anesthetic monitoring protocols, life-threatening complications are still possible. The overall rate of anesthetic complications is extremely low, but such complications always remain a possibility.
Referring Veterinarian's Signature:*

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Out-Patient CT Referral Form

Referring DVM Information

Patient Information