| Referral Service : |
Ultrasound Digital Radiology CT |
| Client Name (first, last): |
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| Client Phone Number: |
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| Would you like us to contact you? |
| Yes No |
| Patient Name: |
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| Breed: |
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| Patient Age or D.O.B: |
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| Sex |
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| Date and Result of Last Felv/FIV or HW/Lyme/Ehrlichia/Ana Test |
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| Current Diet (if prescribed) |
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| Prior Health Problems / Past Pertinent History |
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| Initial Complaint |
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| Current Problem List / Reason for Referral |
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Diagnostics Performed
*(please fax lab reports to 866.895.6030) |
Radiographs
Bloodwork
Cytology/Histopathology
Ultrasound
Urinalysis
Other (please specify)
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| Current Treatment (including dosage) |
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| Referring Veterinarian: |
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| Referring Hospital: |
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| Phone: |
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| Fax: |
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| Email: |
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*When possible, please have faxed to us a copy of the medical records with all lab reports prior to appointment to 866.895.6030. For outpatient CT referrals, only the lab reports and the above form are needed. Outpatient CT scans require a preanesthetic profile within two weeks.
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