Instructions

The more information provided in this form, the faster we can get your patient in and avoid delays.

CT Scans

Outpatient pets will be received by a PAH doctor who will perform a general pre-anesthetic examination prior to the CT procedure. We will call the owner to setup appointments for the patient.

Please inform the client that the findings and any additional treatment plans will be discussed with them by their referring veterinarian.

DVM Information

Referring Doctor(Required)

First Name

Last Name

Phone (DVM)(Required)

Email (DVM)(Required)

Clinic Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Patient Information

Pet Owner(Required)

First Name

Last Name

Pet Name(Required)

Phone (Pet Owner)(Required)

Email (Pet Owner)

Species(Required)

Birthday or Approx. Age(Required)

Breed

Sex(Required)

Male

Female

Spayed / Neutered?(Required)

Yes

Current on Vaccines?(Required)

Yes

Service Requested

CT Scan

CT: Abdomen

CT: Throax

CT: Skull

CT: Vertebrae

CT: Limbs

CT: Full Body

CT: Other

Other CT Scan

It is up to the discretion of your primary DVM to recommend referral to specialty center if case requires.

Upload Records

Drop files here or

Max. file size: 10 MB.

All medical records, prior lab work, and radiographs are required to be uploaded or emailed 24 hours prior to the scheduled CT Scan Appointment.

Chief Complaint

History

Does patient have any foreign metal objects?

Yes

Unknown

Has there been any previous surgeries?

Yes

Potential Risks of Anesthesia

If a patient is anesthetized, a fully qualified veterinary technician working under the direct supervision of a veterinarian will be with the animal throughout the anesthesia and the initial recovery period. In spite of the stringent anesthetic monitoring protocols, life-threatening complications are still possible. The overall rate of anesthetic complication is extremely low, but nevertheless, such complication always remains a possibility.

It is the referring veterinarian’s responsibility to inform the client:

Of anesthesia risk
No food after 10pm the night before the procedure, water is fine

Signature(Required)

CT Referral Form