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? *

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

Head/Neck

Thorax

Abdomen

Pelvis

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? *

I acknowledge that this form is intended to be completed only by the patient’s primary or referring veterinarian. I understand that Hospital for Veterinary Surgery accepts outpatient CT requests for stable cases. Urgent or emergent cases requiring inpatient assessment and management should be discussed directly with one of our surgeons for referral, or referred to a multispecialty facility for immediate care.

Cases that may require future surgical intervention are encouraged to schedule a consultation with one of our surgeons to ensure continuity of care.
Please note that HVS-NY is unable to perform multiphase angiogram studies. We are currently able to perform pre-contrast and post-contrast imaging studies only.

I agree

I disagree

I understand the majority of CT scans require contrast, as it enhances image quality and improves diagnostic accuracy. Contrast is required if it is deemed necessary for the requested imaging. If you have any additional questions or concerns regarding contrast administration for your specific case, please feel free to contact our team directly at info@hvsny.com

I understand that my patient will likely receive CT contrast and must remain on IV fluids for 2 hours post imaging.
*

Yes, please use contrast as necessary to ensure optimal image quality and diagnostic accuracy.

No, I have sent an email requesting further clarification. I understand that a CT scan cannot be scheduled without consent for contrast administration.

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

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