Outpatient CT Referral Form

Client Info
Please fill out on behalf of the client.
Referring Vet Info
For us to provide your patient with the best care possible, please indicate all medical problems, current medications, and history of anesthetic complications or drug sensitivities. Attach any necessary paperwork to complete this request.
CT STUDY
Please check all that apply.
Head/Neck
Contrast included unless otherwise specified
Limb/Joints
Contrast:
Spine
Contrast:
Soft Tissue
Contrast included unless otherwise specified
Include set-up for potential radiation (an additional charge).
Sign above