Outpatient CT Request Form

Is this pet insured?:

Yes
No

Does this client have an ongoing direct insurance claim in progress?:

Yes
No

History, exam findings, differentials:

This text will be passed directly to the reporting radiologist

Name of referring veterinary surgeon:

Name of referring practice:

Telephone Number:

E-mail address to which CT report should be sent:

Address of Practice:

Please confirm if this is an outpatient CT scan that is to be reported by the referring vets:

Select a surgery:

I have read and agreed to the privacy notice: