CT Referral Form

Outpatient referral form for HDVI (High Definition 3D Volumetric Imaging)

Highly recommend sending to a Board Certified Radiologist

**For the safety of the patient, please fill out this form in full. If any information is missing, we are unable to perform procedure**

*Indicates Required Fields

Client Information

Pet Information

Select CT Scan Request - Head and Neck
Select CT Scan Request - Spine
Select CT Scan Request - Soft Tissue
Select CT Scan Request - Limb & Joints – Left
Select CT Scan Request - Limb & Joints – Right
If you selected OTHER , please provide details here
Cardiac
Respiratory
Neurologic
Urinary/Renal
If you selected ABNORMAL  for any of the above, please provide details
List all previous surgeries
Please attach or email a copy of the medical record including blood work and a heart worm test. Generally, blood work is valid for 30 days. If recent bloodwork is not provided, client will be subject to additional fees for performing bloodwork.
One file only.
100 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.
Please attach any imaging that may have been done prior.
One file only.
100 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.
CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.