Family Vet Care Center - CT Scan Patient Referral Form

Referring Veterinarian

Veterinarian Name

First Last

Referring Practice Name

Email To Send Patient Records *(Required)

Client Information

Client Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

Alternate Phone

Patient's Name

Canine ( Dog ) or Feline ( Cat )(Required)

Pre-Op Bloodwork Acknowledgement(Required)

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

File

Max. file size: 8 MB.