Referral CT scan

Referring Practice Details

Referring practice name:

Referring vet name:

Referring vet practice address:

City:

Postcode:

Telephone number:

Email address:

Preferred method of contact:

Client Details

Your Full Name*:

Contact Number:

Pet Details

Pet's Name*:

Your pet's species*:

Pet Breed:

Your pet's date of birth:

Your pet's sex:

Weight (approx.):

Does the pet have implants?:

Yes
No

Your pet's insurance policy number:

Preferred date and time of appointment:

Now

Pre authorisation form:

Yes
No

Clinical History

Modality:

What condition needs investigating?:

Previous anaesthetic protocol/complications:

Relevant clinical history:

Medications:

Area to be scanned:

Specific questions to be answered from CT:

Blood work and relevant clinical history are required within the last month for all patients undergoing sedation or GA, please also send results with this booking form.:

Security Question:

No consent has been selected or the consent is no longer available. Please select one in the field's properties.

I confirm that I have the consent of the above named client to pass the above information to you for the purposes of arranging a CT Scan; and agree to be bound by the South Lincs Vets Privacy Policy (which explains how the data I have submitted data will be used).:

Referral CT scan

Referring Practice Details

Client Details

Pet Details

Clinical History

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