Computed Tomography (CT) Referral Form

* Indicates Required Fields

Referring Veterinarian Information

Referring Veterinarian *

Practice Name *

Address 1

Address 2

City

State

Zip Code

Preferred Contact Method *

Fax

Phone

Client Information

Client Name *

Address 1

Address 2

City

State

Zip Code

Phone *

Mobile

Pet Information

Pet Name *

Species *

Sex *

Breed *

Age *

Patient Information & Related Information

Cardiac *

Respiratory *

Neurologic *

Urinary/Renal *

Patient Information - Abnormal Reasoning

Known Medical Conditions

Allergies & Drug Reactions

Current Medications & Dosages

Previous Anesthetic Complications

Previous Surgeries

Does the patient have, or has the patient ever had, any of the following:

Cardiac Pacemaker *

Orthopedic Implants *

Implanted Shunts / Stents / Intravascular Coils *

Gunshot wounds, Embedded BBs / Pellets *

Microchip *

Foreign Body Ingestion *

Existing Object - Yes Reasoning

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