Online Imaging Referral Form

Online Imaging Referral for Veterinarians

Vaccination Status:
Date Given
Date Given
Date Given
Please fax or email a copy of medical history pertaining to admitting complaint.
Please send a complete copy of results and reference intervals from any lab.
If complex/ ongoing condition, please send medical records showing meds/ treatment.
General Information: General anesthesia is required for all CT examinations. Patients must arrive the morning of the scheduled procedure by 8:30am. The CT Request Form and Referral Form must all be received 48 hours prior to the appointment to facilitate safe anesthesia planning.
SECTION I- Referring Veterinarian Information
Please Note: It is very important that you or one of your associates is available by phone the day of the scan.
SECTION II- CT Scan Requested
SECTION III- CT Report A written report will be sent via email or fax the next working day following the scan.
SECTION IV- Patient Information Refer to the instruction sheet to determine pre-anesthesia required laboratory tests based on ASA status, or call us for assistance. Please note that laboratory values should generally be no more than 2 weeks old.
*ASA 4 or 5 will require referral to IVS
I agree to allow the Institute of Veterinary Specialists to place the report in its patient records for future use.