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Outpatient CT Referral Information Form
Outpatient CT Referral Information Form
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Franklin Animal Clinic
Greenwood Park
Client's Name:
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Address:
Phone (primary):
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Phone (secondary):
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Pet's name:
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Species:
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Canine
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Breed:
Color:
DOB/Age:
Sex:
Intact Male
Neutered Male
Intact Female
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:
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Phone:
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