TVH CT Scan Referral Form

TVH CT Scan Referral Form

We appreciate your referrals for Computed Tomography. We look forward to assisting you with your patient!
We thank you for the opportunity to serve you and your patients. Like you, Tampa Veterinary Hospital is committed to the highest standards of care and service. So we may best serve you and your patient, this form must be filled out in its entirety. Completion of this form constitutes a request for an appointment only. After a thorough review of your request, including a review of patient records a member of the TVH CT team will be in contact with you and your client to coordinate a date and time for the procedure.

Not all patients may be ideal candidates for a CT Scan. TVH reserves the right to decline services for patients whose records reflect one or more significant risk factors, or if the guidelines outlined herein are not followed. Declination of service is at the sole discretion of the TVH Medical Team.

All patients will be under general anesthesia for the scan. Pre-anesthetic bloodwork will be required prior to confirming the CT appointment. Bloodwork results should be sent from the referring veterinarian to referral@tampavet.com no later than 72 hours prior to the scan for review. If bloodwork is not received within this timeframe, the scheduled appointment is subject to cancellation and loss of deposit paid by pet parent. TVH can perform pre-anesthetic bloodwork on the patient if required. This must be scheduled and performed at least 72 hours prior to the scan. Only in the event of critical cases where time is of the essence, exceptions can be made.

Referring DVM must provide all available records- and attach them to this form to be considered for an appointment. Scanned or electronically generated PDF's are preferred. If a file attachment is not possible via this form, records must be sent via email to referral@tampavet.com to complete the referral process.

These guidelines are set to ensure clear communication and expectations among our referring veterinarians, guests and TVH Team members. To begin the referral process, please click Continue.

Referral Information

To be filled out only by referring Veterinarian/Hospital. This form is not to be filled out by client/pet parent.
Your Hospital Name
Name of Licensed Referring Veterinarian

First NameLast Name
Hospital Address

Street Address

Street Address Line 2

CityState

Zip Code
Hospital Main Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referring DVM Mobile Number
In case we need to reach you on an unscheduled day. We will attempt to avoid this whenever possible.Format: (000) 000-0000.
Email Address- where we will send reports and imaging
A regularly checked email is important. Avoid 'general' mailboxes like info@hospitalname.com if possible

Name of Pet Parent

First NameLast Name
Pet Parent Phone Number
We will be contacting them to schedule the appointment.Format: (000) 000-0000.
Pet Parent Email
So we can send them reminders of their appointment
Name of Pet
Breed
Age

Please choose what areas of the patient that require scans
Which limb(s) need to be scanned if applicable?
Do/Does the scan(s) need to be performed with contrast?
Please provide a differential diagnosis of the patient/reason for the scan.
Provide as much information as necessary

I acknowledge that {nameOf19} owned by {nameOf} is being referred to Tampa Veterinary Hospital (TVH), for the sole purpose of performing diagnostic CT Scan(s) by {yourHospital}. TVH will not perform any other general veterinary services unless authorized. I attest that the patient is current on rabies vaccination required by state or local laws and that pre-anesthetic labwork have ben performed within the last 2 weeks, or arrangements will be made to have the tests performed and results ready for viewing no later than 72 hours prior to the scheduled scan.

All results of {nameOf19}'s CT testing will be shared only with agents of Dr. {nameOf33} and {yourHospital}. It is your responsibility to share the interpreted diagnostic results with the pet parent. At the conclusion of the CT scan, the relationship between TVH and {nameOf} is considered complete. Calls or inquiries from the pet parent regarding {nameOf19}'s diagnosis or reports will be referred back to {yourHospital}.
Signature
Date

MonthDayYear
Date

Upload Patient Records

If you are unable to drop files here, please email records to referral@tampavet.com
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TVH CT Scan Referral Form

Referral Information