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Outpatient CT Referral Information Form
Date:
MM slash DD slash YYYY
Location
(Required)
Select a Location
Franklin Animal Clinic
Greenwood Park
Client's Name:
E-mail:
Address:
Phone (secondary):
Phone (primary):
Pet's name:
Species:
Canine
Feline
Other
Breed:
Color:
DOB/Age:
Sex:
Male
Female
Neutered Male
Spayed Female
Medical History, sensitivity to drugs/anesthesia, previous history that may cause complications:
Referral Information:
Myelogram
Abdominal
Head/Jaw/Sinus
Orthopedic
Met/Tumor Check
Requesting CT Consult by Franklin Animal Clinic Veterinarian:
Yes
No
Reason for referral:
CBC and Chemistry run within 30 days of CT Imaging:
Yes
No
Please send lab results, previous imaging, and pertinent records with client.
Referring Veterinarian:
Clinic:
Address:
E-Mail:
Phone:
Fax:
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Phone
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