AHCD - CT Referral Form

CT Referral Form
Veterinarian Name
Name

First NameLast Name
Referring Hospital
Email
example@example.com
Referring Veterinarian Contact Information
Patient Information
Patient Name
Owner Name

First NameLast Name
E-mail (Enter None, If Unknown)
Phone Number
Format: (000) 000-0000.
Species
Breed
Age
Sex
Is Patient Neutered Or Spayed?
Case Information
Tentative Diagnosis
Additional Information (Including Anesthesia Concerns)
What Kind Of CT Are You Requesting?
Organ/Area Of Concern
Head - Area Of Concern
Limb - Area Of Concern
Spine - Area Of Concern
Thorax - Area Of Concern
Would You Like Our Attending Vet To Discuss Results Of CT With Owner?
Has any lab work been performed In the last 30 days? If yes, please email to reception@ahcd.vet. *If no, please inform owner AHCD will perform pre-anesthetic labs, as needed, to ensure patient’s safety.
Have radiographs been taken? If yes, please email to reception@ahcd.vet.
Should be Empty:

CT Referral Form