Outpatient Imaging Form Please enable JavaScript in your browser to complete this form.Referring DVM Information:Name of Hospital or ClinicVeterinarianPreferred Method of Contact:EmailPhoneFaxEmailPhoneFaxPatient Information:Reason for CT ImagingCT Study Request:Head/neckThoraxAbdomenCervical SpineThoracic SpineLumbar/Sacral/PelvisShoulder/ElbowAdditional Requests:IV Contrast Agent (Recommended for abdominal and tumor imaging)Radiologist ConsultationEmail Radiologist Report To:Pet NameBreedSexMMNFFSAge / Date of BirthOwner’s NameOwner's Phone NumberOwner's EmailClient Communication and SchedulingContact the rDVM regarding this referralContact the owner directlyThe owner will contact VDCNCIf you chose, "contact the owner directly" - would you like us to email or call them?Digital Radiographs Available?YesNoAttach File 1 Click or drag a file to this area to upload. Attach File 2 Click or drag a file to this area to upload. Attach File 3 Click or drag a file to this area to upload. Attach File 4 Click or drag a file to this area to upload. Outpatient CT imaging is available for dogs and cats. All CT imaging patients will undergo brief general anesthesia and services will include a preoperative examination, premedication, IV catheter placement, and comprehensive multi-parameter monitoring. The imaging study will be evaluated for diagnostic quality, but diagnostic findings will not be discussed with the client. The client will receive a thumb drive with the images at the time of discharge. Minimum requirements for scheduling include: physical examination findings, chemisitry panel/complete blood count, thyroid level (all cats > 10 years of age) and a completed referral form. Examination and lab tests will need to be completed no more then 30 days prior scheduled appointment. *I have read and understand.PhoneSubmit