CT Referral Form
Veterinarian Name
Name
*
First Name
Last Name
Referring Hospital
*
Email
*
example@example.com
Referring Veterinarian Contact Information
*
Patient Information
Patient Name
Owner Name
*
First Name
Last Name
E-mail (Enter None, If Unknown)
*
Phone Number
*
Species
*
Canine
Feline
Breed
Age
*
Sex
Is Patient Neutered Or Spayed?
Yes
No
Case Information
Tentative Diagnosis
*
Additional Information (Including Anesthesia Concerns)
What Kind Of CT Are You Requesting?
Please Select
Abdomen
Head
Limb (R Front , L Front, R Rear, L Rear)
Spine (Cervical, Thoracic, Lumbar, Lumbosacral, Sacral)
Thorax (Organ)
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?
*
Yes
No
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.
*
Yes
No
Have radiographs been taken? If yes, please email to reception@ahcd.vet.
*
Yes
No
Submit
Should be Empty: