Small Animal CT Form in Irving, TX

WE HIGHLY RECOMMEND THAT YOU SUBMIT ALL RELEVANT MEDICAL RECORDS AND LAB WORK SO WE CAN BE PREPARED FOR EACH CASE.

Patient Information
Patient Name*
Age
Gender
Patient Weight
Breed
Date of Request
Owner's Name*
First Last
Owner's Phone*
Owner's Address
Street Address City State / Province / Region ZIP / Postal Code
Other Authorized Party/Relationship
Phone
Referring Veterinarian Information
Referring Veterinarian*
Phone*
Clinic Name*
Address
Street Address City State / Province / Region ZIP / Postal Code
Email
Fax
Please send any radiographs taken at your clinic for your client’s appointment
Each patient should have a physical exam, CBC, chemistry panel and 3-view chest radiographs (if > 6 years old) prior to the CT exam to evaluate anesthetic risk (approximately 1.5 to 2 hours). Please send lab results and/or x-rays with this order if available. Intravenous iodinated non-ionic contrast is used on most CT studies
Please check the exam you are prescribing for this patient
If Other
Specific Area of Interest
Working diagnosis and reason for exam
Symptoms
Surgical clips present?
- Yes
- No
Foreign metal objects?
- Yes
- No
If yes, Where?
Previous surgery?
- Yes
- No
Additional Exam you are prescribing
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Patient Information