Client Name* First Last Phone*Patient InformationPatient Name* Weight* Please specify weight in Kg/Lb.Species* Breed* Sex*Please SelectMaleFemaleReferral InformationHospital Name* DVM* Phone*Email* Is a Consultation with a specialist requested?*Please SelectYesNoNote: Consultation appointments will be set up with the specialist prior to the scan being performed. The CT fee does not include the specialists office visit fee. Department Area(s) to be scanned* Particular areas of interest within area(s) of scan:* Note: This information will be needed for the radiology review.Contrast requested*Please SelectYesNoNote: Contrast fee will be dependent on the patient’s weight.Pre-anesthetic concerns*Date of last blood panel* MM slash DD slash YYYY Upload a copy of last blood panel*Max. file size: 15 MB.What blood work would you like performed?*Current Medications*CAPTCHA