CT Referral Request Form Please enable JavaScript in your browser to complete this 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):EmailFax(we will use the email/fax information listed above)Client InformationName *FirstLastAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome PhoneCell PhoneEmail *Pet InformationNameAgeBreed/ColorSexWeightSpecies*CanineFeline*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 MedicationsAnatomic Region of Interest: Presenting Complaint/History: Physical Exam Findings:Pertinent Laboratory or Imaging Findings: Preliminary/Tentative Diagnosis:Specific Clinical Questions/Concerns:Additional Comments:WebsiteSubmit