Outpatient CT Referral Form

Location*

Referring Veterinarian Information

Date*

Referring Veterinarian*

Referring Hospital*

Phone*

Fax*

Address*

Primary Veterinarian Information

(If different than referring veterinarian)

Primary Veterinarian

Primary Hospital

Phone

Fax

Address

Patient & Client Information

Patient Name*

Owner's Name*

Phone*

Email*

Species

Canine
Feline

Breed*

Weight*

Color*

Age*

Sex

Male
Neutered Male
Female
Spayed Female

History

General Patient History (Significant Medical Problems & Patient's Current Status)*

Area of Study

If "Extremity" is selected, specify here:

(All studies except thoracic metastasis screen will include contrast administration)

Study Needed for:

Diagnosis
Surgical Planning

Additional Notes to Radiologist:

Diagnostic Results & Interpretation

(Please attach copies of reports that are current within 30 days)

CBC with Differential:

Complete Biochemical Profile (or Liver/Kidney/PCV/TS Minimum):

Retrovirus testing for FELV and FIV:

Two view thoracic and abdominal radiographs/AUS findings:

Additional Diagnostic Test Results:

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Name

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