Outpatient CT Referral

Head:

Thorax:

Abdomen:

C1-T2 (or neck):

T3-sacrum:

Forelimbs:

Shoulder:

Elbow:

Carpus:

Metacarpals/phalanges:

Hindlimbs

Hips / pelvis:

Stifle:

Tarsus:

Metatarsals/phalanges:

Further imaging requirements (e.g. if long bones are to be scanned):

Select Urgency:

Please always phone practice to discuss BEFORE urgent CT referral.

Practice details

Referring practice name*:

Referring practice postcode*:

Case vet's first name*:

Case vet's surname*:

Practice Email (Vet CT Report will be sent to this address):

Add my email to the list for veterinary professionals for updates on CPD and other news:

Yes please!

Practice Telephone Number:

Client Details

Client Title*:

Client First Name*:

Client Surname*:

Client Address Line 1*:

Client Address Line 2:

Client City*:

Client Postcode*:

Client Telephone*:

Client Mobile:

Client Email:

Patient information

Patient Name*:

Species*:

Breed*:

Age*:

Sex*:

Neutered:

History and general health*:

More detailed information can be uploaded in the Attachments section.

Questions to be answered:

Tick if the patient has:

Details of the above:

Has this animal been imported or travelled abroad?:

Yes
No

If yes, has this animal had a negative Brucella antibody test at least 3 months after return to the UK?:

Yes
No

Please note, we will not accept referrals for travelled animals without evidence of a negative Brucella test. Positive animals will unfortunately not be accepted for referral.

Upload relevant history or other files

Please attach the appropriate case history and any additional records e.g. test results, radiographs, ECG tracings etc (Max total file size 8MB).

Attach Animal History:

Additional Information:

Insurance

Is the animal insured?:

Yes
No

Insurance Company:

Policy Number:

Policy Limit Amount:

It is the responsibility of the referring practice to send up to date history and relevant lab work prior to the patient being seen.

NOTE: By submitting this form you confirm that you are a qualified veterinary surgeon who has obtained consent from the patient’s owner to act on behalf of the animal described above; that the owner has given permission for the administration of an anaesthetic/sedative to the above animal at the imaging location together with any other procedures that may prove necessary; and that the owner understands that in the unlikely event of an emergency or where additional pain relief or sedation may be required, the imaging branch will act in the best interests of the patient.; that the owner has agreed that they have understood that medicines may be used which are not licensed for use in dogs and cats; and that in the event that you cannot be contacted on the above number, you understand that the imaging branch will act in the best interests of the patient.

Security Question:

Outpatient CT Referral

Please ensure that you select every area you wish to be scanned below. If you are unsure of which areas you need to scan, please phone 01626 367972 and ask to speak to one of the CT referral vets for advice.

Forelimbs:

Hindlimbs

Practice details

Client Details

Patient information

Upload relevant history or other files

Insurance

It is the responsibility of the referring practice to send up to date history and relevant lab work prior to the patient being seen.

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