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

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

Attach File 2

Attach File 3

Attach File 4

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.