Computed Tomography (CT) Referral Form When requesting an outpatient CT study, the requesting clinician will be solely responsible for communicating the results and making treatment recommendations based on the findings. Only referring veterinarians can request an outpatient CT. Please complete the form below and upload or email the patients most recent 2 years of medical records, lab work and radiographs when applicable to avonanimal@gmail.com. After review of the submitted information, a CT technician will be in contact for scheduling. Outpatient CT patients need to be fasted 12 hours ahead of their scheduled procedure and should be expected to be at the hospital for the morning of their procedure. Pets will be undergoing anesthesia and awners should expect a shaved area to facilitate the placement of an Intravenous catheter. CT patients require current bloodwork including a complete CBC and Chemisty profile.Referring Veterinarian InformationReferring Veterinarian*Practice Name*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Preferred Contact Method*FaxPhoneEmailFaxPhoneEmail Client InformationClient Name*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*MobilePet InformationPet Name*Species*CanineFelineSex*MMCFFSBreed*Age*Select CT Scan RequestHead & Neck Entire Skull Nasal Cavity Brain Osseous bullae Orbits Sinuses TMJ Soft Tissue Others Head & Neck: Other*Spine C1-T2 T3-L3 L4-Sacrum T10-Sacrum T3-Sacrum C1-Sacrum Other Spine: Other*Soft Tissue Chest Wall Lungs (Met Check) Chest Soft Tissue Abdomen Other Soft Tissue: Other*Limb & Joints - LEFT Brachial plexus Stifle Elbow Hip Pelvis Shoulder Other Limb & Joints - LEFT: Other*Limb & Joints - RIGHT Brachial plexus Stifle Elbow Hip Pelvis Shoulder Other Limb & Joints - RIGHT: Other*Patient Information & Related InformationCardiac*NormalAbnormalRespiratory*NormalAbnormalNeurologic*NormalAbnormalUrinary/Renal*NormalAbnormalPatient Information - Abnormal ReasoningIf you selected ABNORMAL for any of the above, please provide detailsKnown Medical ConditionsAllergies & Drug ReactionsCurrent Medications & DosagesPrevious Anesthetic ComplicationsPrevious SurgeriesList all previous surgeriesDoes the patient have, or has the patient ever had, any of the following:Cardiac Pacemaker*YesNoUnknownOrthopedic Implants (plates, screws, pins, artificial joints, etc)*YesNoUnknownImplanted Shunts / Stents / Intravascular Coils*YesNoUnknownGunshot wounds, Embedded BBs / Pellets*YesNoUnknownMicrochip*YesNoUnknownForeign Body Ingestion*YesNoUnknownExisting Object - Yes ReasoningIf you answered YES to any of the above, please provide detailsI desire to read the CT images myself and do not require an official radiologist report on the CT findings (24-48 hours post scan)*YesNo, please send copy of images via email and a radiologist reportCAPTCHAEmailThis field is for validation purposes and should be left unchanged. 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