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:MessageSubmit