CT Scan Referral | Beacon Vet

Client Name*

First Last

Phone*

Patient Information

Patient Name*

Weight*

Please specify weight in Kg/Lb.

Species*

Breed*

Sex*

Referral Information

Hospital Name*

DVM*

Phone*

Email*

Is a Consultation with a specialist requested?*

Note: 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*

Note: Contrast fee will be dependent on the patient’s weight.

Pre-anesthetic concerns*

Date of last blood panel*

Upload a copy of last blood panel*

Max. file size: 15 MB.

What blood work would you like performed?*

Current Medications*

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