Outpatient Imaging Form – Veterinary Dental Clinic of North Carolina

Referring DVM Information:

Name of Hospital or Clinic

Veterinarian

Preferred Method of Contact:

Email
Phone
Fax

Email

Phone

Fax

Patient Information:

Reason for CT Imaging

CT Study Request:

Additional Requests:

IV Contrast Agent (Recommended for abdominal and tumor imaging)
Radiologist Consultation

Email Radiologist Report To:

Pet Name

Breed

Sex

M
MN
F
FS

Age / Date of Birth

Rabies Vaccination Expiration Date *

Owner’s Name

Owner's Phone Number

Owner's Email

Client Communication and Scheduling

Contact the rDVM regarding this referral
Contact the owner directly
The owner will contact VDCNC

If you chose, "contact the owner directly" - would you like us to email or call them?

Digital Radiographs Available?

Yes
No

Attach File 1

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Attach File 2

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Attach File 3

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Attach File 4

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Cone Beam CT imaging is available for dogs and cats. Consultation examination is required for all CT imaging patients. If you have more photos or files to send, please email them directly to info@vdcnc.com. Referral requests are reviewed within one business day of submission. VDCNC hours of operation are Monday-Thursday, so referrals submitted on Thursday and Friday will be reviewed on the following Monday. *

I have read and understand.

Cone Beam CT Form