CT Referral Form

You may complete this form online and then click “send” to submit the referral to our hospital, or click here to download & print a PDF copy of the CT Referral Request.

Referring Veterinarian Information
Date* Referring Doctor*
Referring Hospital* Hospital Phone*
Hospital Address
Client Information
Client* Client Phone*
Client Address
Patient Information
Patient Name* Species*
DOB Gender
Breed Weight
Tentative Diagnosis*
History
Clinical Symptoms
CT Images Requested
Please select all that apply, and specify segments or requests in the field below.
BrainSinusesAbdomenThorax
Cervical Spine (specify segment)Thoracolumbar Spine (specify segment)
Hip LeftHip RightStifle LeftStifle RightShoulder LeftShoulder Right
Elbow LeftElbow RightCarpus LeftCarpus Right
Other (please specify)
Specific segments or other notes:
Referral Agreement

It is the policy of Animal Medical & Surgical Center that we will treat your pet only for the specific procedure for which you were referred and cannot provide any veterinary care other than that requested by the primary veterinarian.

It would be considered a breech of the ethics of our profession to assume any pet’s veterinary care that would normally be provided by the veterinarian that has referred you to us.

I understand that my patient is being referred to Animal Medical & Surgical Center for CT Imaging only.

By submitting this form, I acknowledge that I have read and agree to the above referral policy of Animal Medical & Surgical Center.

Signature of Referring Veterinarian* Date*