Referring DVM Outpatient CT form

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Please complete the below information to request an outpatient CT.

Hospital for Veterinary Surgery

Referring Facility *

Referring DVM, first and last name *

What email should the finalized radiology report be sent to? *

Referring Facility phone number *

Referring Facility Address *

Client, first and last name *

Client phone number *

Patient name *

Species *

Breed

Patient DOB *

YYYY

Presenting complaint *

Brief history *

What region are you requesting to CT? *

Head/Neck

Abdomen

Thorax

Forelimbs- please specify below (toes to shoulders, elbows, etc)

Hindlimbs- please specify below (toes to stifles, pelvis, etc)

Other:

Required

If forelimbs/hindlimbs, please specify regions to include, or n/a *

Were radiographs performed? *

Was preanesthetic bloodwork (CBC/Chemistry) performed? *

Will you want contrast? *

Yes

I understand HVS will not contact owners to schedule the outpatient CT until records, including radiographs and bloodwork are received.

Records can be sent to info@hvsny.com

I agree

I disagree

I understand that the Hospital for Veterinary Surgery is not responsible for reviewing radiology results with owners. Finalized radiology reports will be returned within 2 business days. I understand a STAT read can be requested for an additional fee for more immediate results. *

I agree

I disagree

Submit

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