CT Referral Form

CT Referral Form

Referring Veterinarian Information
Referring Hospital*
Email for Report and Images*
example@example.com
Referring Hospital*
Veterinarian Information*

First NameLast Name
Best Contact Number for Veterinarian*
Please enter a valid phone number.

Client Information
Client Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient Information
Patient First Name*
Species*
Date of Birth*

MonthDayYear
Date
Is DOB Estimated or Known? *
Patient Sex
Patient Colour/Markings

Scheduling
Availability

We are able to aquire CT images 24/7/365. Should you need immediate services, we are able to see any patient same day (or evening) through our emergency department. We also offer regularly scheduled appointments. Please indicate both how quickly we need to aquire a scan and how quickly you need results (pricing will depend on how quickly you need results).

If you need emergency services, please call us at 1.406.252.4159.

Turnaround

Idexx Offers the Following Services. Turnaround times do vary depending upon volume, so these times are offered only as a general guide.

Routine: ~ 24 Hours*
Priority: ~ 12-16 Hours (Weekend Available)
Stat: ~ 4-7 Hour (Weekend Available)

*Weekend services are limited to priority and stat submissions. We are able to aquire images for a weekend submission with routine turnaround, but the turnaround time starts on Monday morning.
Aquisition Timeframe*
Turnaround Requirements*
If we have not already been in contact, who should we contact to schedule? *
Scheduling Notes

Region Aquisition
A Note about Study Definitions
Interpretation from our radiologists is based on the number of regions submitted. Note that Moore Lane Veterinary Hospital will quote for 1 additional region beyond those we expect to submit. The reason for this is that radiologists are liable to interpret any anatomy submitted. We will only charge the client for the number of studies IDEXX radiology charges. Please see below for study definitions.

One Study Submission Examples
- Brain
- Skull/Head
- Thorax
- Abdomen
- One Level Spine (Cervical, Thoracic, or Lubar)
- Pelvis
- Shoulders
- Stifles or elbows
- Carpi or Tarsi (Including Distal Skeletal Structures)
Two Study Submission Examples
- Thorax and Abdomen
- Brain and One-Level Spine
- Two-level Spine
- Brachial Plexus
- Lumbar Plexus
- Pelvis and Stifles
- Shoulders and Elbows
Three Study Submission Examples
- Three-Level Spine
- Lumbar Spine, Pelvis, and Stifles
- Cervical Spine and Full Thoracic Limbs
Four-Study Submission
- Full Spine
- Any Combination of Four Studies
Whole Body Sumbmission
- Available for any case, but must be denoted on form
Region(s) of Interest and Anatomy of Interest within Region(s)*
By default, we will send you a copy of the bulk data acquired for this CT scan. This will be shared via a web browser that will allow you to see an axial view of the anatomy submitted to our radiologist. If you are unable to process an MPR in house and would like to see additional views, we are happy to process an MPR for your purposes (this would allow you to see sagittal and coronal views). If you are interested in additional image processing, please indicate this below, including the views and anatomy of interest for this purpose. Note that our radiologists produce their own MPRs based on the bulk data we send.
Region Acknowledgement*

We will quote the client for 1 region more than anticipated, but only charge for the number of regions we are charged by our radiologists. Please check to acknowledge.
Data Acknowledgement*

Copies of all bulk data and MPRs we send to you will be permanently stored within our PACs system. We will keep raw data locally for at least 72 hours - this is a space-intensive file that contains a significant amount of extraneous information. If you need a study processed using a different algorithm (ie soft tissue vs bone), or collimated differently, please inform us during this timeframe and we are happy to reprocess this bulk data at no additional charge.
In the event that we need to perform an additional image acquisition due to our acquisition technique, we will not charge the owner for additional acquisition. If this is the case, would you prefer that we contact the owner directly, or contact the referring veterinarian listed above?*

Contact the Referring VeterinarianContact the Owner Directly

Contrast, Sedation, and Anesthesia
Anesthesia and Sedation

We include an IV catheter, fluids (if deemed appropriate by the attending DVM), and injectable sedation with all CT aquisitions. Isoflurane is not included as standard but will be administered if appropriate.

Contrast

For the majority of studies, we will collect both pre and post contrast images.

Diagnostic Requirements

We require a preoperative blood panel prior to sedation and image aquisition. This should include, at minimum a CBC and basic Chemistry (including liver and kidney values). We are able to perform blood work prior to the scan if requested. Bloodwork must be collected within 7 days of the patient's CT Scan.
Presurgical Bloodwork*
Pre-surgical Bloodwork Results

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Clinical History
The information you submit will be sent to or summarized for our radiologists.
History/Clinical Signs Summary*
Summary of PE Findings*
Diagnostics and Brief Summary*
Treatment, Including Treatment Plan*
Additional Information
Full Records*

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Post-Scan Follow Up
What You Can Expect From Moore Lane

Immediately following our scan aquisition, you will be emailed the bulk data from the scan (referenced previously). We will also share the vetmedstat case with you. Initially, when clicking on this link, you will see the information we submitted to IDEXX VetMedStat as well as the ETA for the radiologist's full report, accessible from the same link.

In the meantime, if there is anything you need, we can be reached at 1.406.252.4159 or at moorelanevethospital@nva.com.

Our Commitment to a Quality Referral Experience

We are here to support you as fellow members of the veterinary community. We're commited to timely and transparent referral services. We remain open to and encourage any feedback or suggestions to improve that process for you and/or your colleagues.

Communication with Owner

We will communicate with owners only to schedule and arrange for pickup of the patient. Beyond that we will set the following expectations with owners:
- Follow up or ongoing care should be kept with the referring veterinarian for continuity of care.
- We will communicate results to the referring veterinarian, who will contact the owner about results.
- All records of the patient's visit at Moore Lane Veterinary Hospital will be sent to the referring veterinarian.
- If the patient is going home the same day as their CT scan, we are availble through the evening should they have concerns about their pet's sedation/anesthesia.
Payment Expectations

We will collect payment for CT aquisition at the time of pickup. Please note the best contact information for payment (we prefer to collect directly from an owner rather than from your hospital). We accept all major credit cards per phone, and can accept all major credit cards, cash, Care Credit, or Scratch Pay in person. We are unable to accept checks.
Contact Number for Patient Pickup*
Please enter a valid phone number.
Pickup Information*
Private questions or concerns for Moore Lane Veterinary Hospital
Type a question
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