Referring Veterinarian

Referring Veterinarian *

Clinic Name *

Clinic Address *

Clinic Phone *

Clinic Fax

Clinic Email

Owner Information

Owner's Name *

Owner's Phone *

Owner's Email

Pet Information

Pet Name *

Species *

Canine
Feline
Rabbit
Ferret
Avian
Reptile
Amphibian
Other
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Breed *

Color *

Birthday *

Sex *

Male (Not Neutered)
Female (Not Spayed)
Male (Neutered)
Female (Spayed)
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Current Weight (kg) *

Patient Condition *

Healthy
Stable
Critical
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Is there metal in the patient? *

Yes

No

Had Previous Anesthesia or Surgery? *

Yes

No

Anesthetic Risk (ASA Status): *

None
ASA 1 - Excellent
ASA 2 - Good
ASA 3 - Fair
ASA 4 - Poor
ASA 5 - Grave
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Any known reactions to sedation/ anesthesia? *

Primary Medical Concerns (include pertinent medical history) *

Pertinent Diagnostic Results

Please upload pertinent lab/testing results

Current Medications (include mg/kg dose)

CT Request Information

CT Scan Region(s): *

Abdomen
Thorax
Extremity
Head
Whole Body
Other (please describe)
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If other, please specify

Supporting Documentation

Upload radiographs, lab results, or notes (PDF, JPG, DICOM)

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