CT Referral Form

rDVM Information
Hospital Address:
Preferred Contact Method:
Client and Patient Information
Client Address:
Phone type:
Species:
Current on vaccines?
Spayed or neutered?
Sex:
CT Examination Requested
Abdominal:
Thorax:
Cervical:
Cranium:
Spine:
Musculoskeletal:
Potentional Risk of Anesthesia: If the patient is anesthetized, a fully qualified technician working under the direct supervision of a veterinarian will be with your pet throughout the anesthesia and the initial recovery period. In spite of stringent anesthetic monitoring protocols, life-threatening complications are still possible.The overall rate of anesthetic complications is extremely low, but nevertheless, such complications always remain a possibility.
 
Client has been informed of all risks and possible complications and has given consent to proceed.
Client has been reminded:
For Referring Vet ONLY: I have reviewed and completed this form for submission to Standiford Veterinary Center for the evaluation of my patient.