Small Animal – CT Form WE HIGHLY RECOMMEND THAT YOU SUBMIT ALL RELEVANT MEDICAL RECORDS AND LAB WORK SO WE CAN BE PREPARED FOR EACH CASE. Patient InformationPatient Name*AgeGenderPatient WeightBreedDate 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/RelationshipPhoneReferring Veterinarian InformationReferring Veterinarian*Phone*Clinic Name*Address Street Address City State / Province / Region ZIP / Postal Code Email FaxPlease send any radiographs taken at your clinic for your client’s appointmentSent DigitallySent with ClientNone TakenEach 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 studiesPlease check the exam you are prescribing for this patientChoose OneCT of Skull / Nasal PassageCT of SpineCT of General AbdomenCT of ThoraxCT of ElbowsOtherIf OtherSpecific Area of InterestWorking diagnosis and reason for examSymptomsSurgical clips present? Yes No Foreign metal objects? Yes No If yes, Where?Previous surgery? Yes No Additional Exam you are prescribingAdd AttachmentsCAPTCHA