NHVH - CT Referral Form

CT Referral Form
Please complete all fields of the following form.

Once submitted you will be emailed a copy and one of our staff will be in touch with you to confirm time and details of appointment.

The results of the CT scan will be reported directly to you, the referring veterinary surgeon, by email, within 2-5 days or sooner if requested.

North Hobart Veterinary Hospital will invoice your client on the day of service. Payment is due at the time of admission.

Patient transport is available to practices in Southern Tasmania by arrangement.
Do you require patient pick up and drop off from your practice?
Please fill in fields required*
Referring Practice Details
Referring Practice:
Referring Veterinary Surgeon:
Telephone:
Referring Practice Email:
Client Details
First Name:
Last Name:
Mobile:
Client Address:
Pet/Animal’s Details
Name:
Species:
Breed:
Age:
Sex:
Neutered:
Weight:
CT Scan Details
What is your primary region of interest for this scan?
Areas to be scanned:
Area images reference diagram. Click here to view.

CT Costs

1 region $2,420 inc GST
2 regions $2,710 inc GST
3 regions $3,070 inc GST
4 regions $3,430 inc GST

Depending on the scan regions requested, North Hobart Veterinary Hospital will confirm estimated costs prior to booking. If you have any questions, please call us on 6220 1380.

Is this patient likely to need a myelogram? (added cost for myelogram $600):
If you are requesting a myelogram, please ensure your client has an understanding of the possible and immediate long term risks. View CT myelogram risk document
Contrast may be used for CT scans. Please confirm that the risks of contrast have been discussed with your client:
Do you require a STAT reading? (*Note: an additional $150 applies)
Preferred scan date 1:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Preferred scan date 2:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
History (compulsory)
Summary of Patient History:
Questions to be answered / Differential diagnosis:
Upload patient history, images or blood test results:
Patient history - Upload 1

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Images - Upload 2

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Additional Uploads

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We recommend a pre anaesthetic blood test within 3 months of scan. Please tick to confirm whether pre-operative bloods have been performed prior to admission.
*If no North Hobart Veterinary Hospital will run in-house pre-anaesthetic blood screening prior to patient scan, added cost $170.
Upload blood work:

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Other test results and current medication:

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In most cases the CT scan will be performed under heavy sedation or general anaesthesia. Please remind owners of appropriate fasting times for their pet.
Should be Empty:

CT Referral Form

Referring Practice Details

Client Details

Pet/Animal’s Details

CT Scan Details

History (compulsory)