Outpatient CT Referral Form

Outpatient CT Referral
Clinic Name:*
Clinic Name*
Clinic Contact Information:*

Clinic PhoneClinic Email
Veterinarian Contact Information:*

Veterinarian NameVeterinarian Email
Client Contact Information:*

Client PhoneClient Email
Client/Pet Information:*

Client's Full NamePet's Name
Patient FAS Score
https://fearfreepets.com/fas-spectrum/
Clinical history / presenting complaint:*
Body region(s) to be scanned: Each region requested for diagnostic imaging will be billed as a separate charge.*

AbdomenHeadNeckThoraxElbowShoulderTarsusCarpusStiflePelvisMetcheck
Please indicate which side Left Right N/A*
Would you like your patient to receive IV contrast? Yes No Unknown*
Additional notes for CT imaging goals:
Relevant diagnostics performed (e.g blood work, x-rays - please link if available):*
Blood work must be completed within 6 weeks of CT scan
ASA score + precautions or concerns for anesthesia:*
ASA Reference: https://www.avtaa-vts.org/asa-ratings.pml
Current medications:*
Relevant Records / X-Ray JPEGs

Cancelof
Please select one of the following options regarding image review:*

Send images to VSx's default radiologist for interpretation. Results will be forwarded once completed.Send raw images directly to your practice without interpretation.
Should be Empty: