Referring Veterinarians Form

Referring Veterinarians Form
Date*

MonthDayYear
Primary Clinic / Hospital*
Primary Veterinarian*
Phone*
Fax*
Email*
Client Name*
Phone*
Patient Name*
Species*
Breed*
Gender*
Age*
Weight: lbs, kg*
Significant History (include concurrent conditions, anesthetic concerns, previous surgeries, cardiac or respiratory disease concerns):
Diagnostics Performed
Pertinent Results
Tentative Diagnosis
Current Medications/Therapies
Questions you want to be answered from consult
Reason for imaging request
Ultrasound request: (Abdomen/Echo)
CT Service Request

Please note multiple regions will affect cost.
Skull Spine

CervicalThoracicLumbarFull spine (2 regions)
Soft Tissue

Chest WallChest Soft TissueLungs (Met Check)AbdomenOther
Limb and Joint: Right

ShoulderElbowPelvisHipStifleOther
Limb and Joint: Left

ShoulderElbowPelvisHipStifleOther
Iodinated Contrast Material
please note additional costs and hospitalization may occur.
**As State Avenue Veterinary Clinic assumes the liability and responsibility of performing anesthesia and the CT examination, we ultimately reserve the right to refuse to perform the computed tomography examination if the pet is deemed unsuitable as a candidate for general anesthesia.
Consent*

I acknowledge that the full medical records need to be submitted to stateavevet@gmail.com
Should be Empty:

CT Service Request