Veterniary CT Scan Referral Form

Patient Referral Form

This form is to be completed by clinics that are referring canine or feline patients to Family Vet Care Center for CT scans.

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Referring Veterinarian

Name

First

Last

Referring Practice Name

Email To Send Patient Records

Client Information

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Alternate Phone

Patient Name

Email

Canine ( Dog ) or Feline ( Cat )

Pre-Op Bloodwork Acknowledgement

Pre-Op Bloodwork is always recommended prior to CT Scans. Will you be performing this routine bloodwork at your facility? If yes, please forward bloodwork results with records.

CT Body Region +/- Contrast

Most radiologists recommend Contrast CT to enhance images and obtain better diagnostic results. Caution should be used in patients with kidney insufficiency.

Weight / Age / Sex / Breed

Differential Diagnosis

Patient History

Current Medications / Supplements

Please submit any pertinent patient records and images below. You may also email records and diagnostics to info@familyvetcarecenter.com

Referring Pre-Op (

File Upload

Click or drag a file to this area to upload.