CT Scan Referral Form

Referring Clinic Information

Clinic Name
Date
Referring Veterinarian
Clinic Email
Clinic Phone

Client Information

Name
Contact
Email

Patient Information

Name
Species
Breed
Sex
Date of Birth
Weight
Microchip

Appointment Request

Date
Time
The patient will come with

Patient History

Please give a brief overview of your medical history, diagnosis, chronic conditions, anesthetic reaction,known allergic reaction, and sensitivities.
Medications (List all of current medications and dosages, and mention any dietary restrictions)
Latest Biochemistry and CBC Results
Please take note that results must be received no later than two days before the planned scan date (Mandatory for Anaesthesia)
Has the patient undergone a CT scan before?
Is there internal metal, hemoclips, or a pacemaker in the patient?
If Yes, please describe

CT Scan Reasons or Preliminary Diagnosis

Any Queries to be Addressed

Anatomical Region(s) to be Scanned

Each region is regarded as single scan. Choosing multiple areas lengthens the time needed for anaesthesia, scans, and fees.

Reporting Images

For interpretation, the images will be forwarded to a certified radiologists in the UK. Following the completion of the scan, the referring veterinarian will receive the complete report.
For interpretation, the images will be forwarded to a certified radiologists in the UK. Following the completion of the scan, the referring veterinarian will receive the complete report.
up to 7 working days
up to 36 hours (Business days only)
up to 6 hours
up to 24 hours after
- Business days from Monday 12:30PM till Friday 9:30PM
- Weekend from Friday 9PM till Monday 12PM
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