CT Referral Request Form

Referring Veterinarian: *

Phone: *

Referring Hospital:

Preferred Method of Contact:

Clinic E-mail: *

Clinic Fax:

I am referring this patient to AMCS for (Please check the correct box below):

• CT only (imaging report will be sent directly to the referring DVM, AMCS will not consult or share results with the owner)

I prefer to receive my final imaging report via (the report will be sent within 24-48 hours):

• Email
• Fax

(we will use the email/fax information listed above)

Client Information

Name *

First

Last

Address

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Home Phone

Cell Phone

Email *

Pet Information

Name

Age

Breed/Color

Sex

Weight

Species*

• Canine
• Feline

*Please note we only see cats and dogs.

Please attach the following supplemental information (This will assist us in preparation of a complete history for CT request forms):

Click or drag files to this area to upload. You can upload up to 15 files.

Please be sure to remind your client:
□ No food after 10pm, water is ok
□ Bring radiographs
□ Bring Medications

Anatomic Region of Interest:

Presenting Complaint/History:

Physical Exam Findings:

Pertinent Laboratory or Imaging Findings:

Preliminary/Tentative Diagnosis:

Specific Clinical Questions/Concerns:

Additional Comments:

Name

Submit