CT Referral Request Form

Today's Date(Required)

Referral Information

Referring Veterinarian(Required)

Referring Hospital(Required)

Clinic Email(Required)

Clinic Phone(Required)

Clinic Fax

Preferred Method of Contact(Required)

Phone

I prefer to receive my final imaging report via:(Required)

Fax

Client Information

Name(Required)

First Last

Address(Required)

Street Address City State ZIP Code

Home Phone(Required)

Cell Phone(Required)

Email(Required)

Owner's Preferred Method of Contact(Required)

Phone

Pet Information

Name(Required)

Birthday (Approximate Age)(Required)

Species(Required)

Dog

Cat

Breed/Color(Required)

Sex(Required)

Male

Male - Neutered

Female

Female - Spayed

Weight(Required)

Anatomic Region of Interest (Check all that applies)

Head & Neck

Entire Skull

Brain

Orbits

TMJ

Nasal Cavity

Osseous Bullae

Sinuses

Soft Tissue

Other

Head & Neck - Other(Required)

Thorax

Chest Wall

Chest Soft Tissue

Lungs

Abdomen

Limb & Joints

Right

Left

Brachial Plexus

Elbow

Shoulder

Stifle

Hip

Pelvis

Other

Limb & Joints - Other(Required)

Spine

C1 - T2

T3 - L3

L4 - Sacrum

Other

Spine - Other(Required)

Other

Other - Description(Required)

Presenting Complaint/History:

Current on Vaccinations(Required)

Yes

History of Seizures(Required)

Yes

History of Kidney Disease(Required)

Yes

History of Heart Disease(Required)

Yes

Known implants (pacemaker, orthopedic, stents, coils, BB/pellets)

Yes

Other known medical conditions:

Previous anesthetic complications:

Previous surgeries:

Current Medications and Dosages:

Pertinent Physical Exam Findings:(Required)

Pertinent Laboratory or Imaging Finding:(Required)

Preliminary/Tentative Diagnosis:(Required)

Specific Clinical Questions/Concerns:(Required)

Additional Comments:

Medical Records Upload

Please upload the following supplemental information: Pertinent medical records, Labwork (with 1-2 months), and Radiographs. This will assist us in preparation for CT. You can alternatively email or fax them to our hospital at time of request at [email protected] or (701) 478-9298.

Drop files here or

Accepted file types: jpg, pdf, Max. file size: 5 MB, Max. files: 10.

Please be sure to discuss the following with your client:

Please inform client that the CT findings and any additional treatment plans will be discussed with them by you, the referring veterinarian.
Discuss that this is an outpatient CT. The pet will be received by a doctor at RRAEH who will perform preanesthetic examination prior to the procedure.
Discuss requirement of either sedation or anesthesia.
Cost. Estimated cost $1000-$1400 for one cavity scan. This depends on use of sedation or anesthesia and area to scan. Client will get an estimate on the day of the CT with a more approximate cost from RRAEH.
A representative from RRAEH will contact the owner once a doctor at RRAEH reviews the referral to schedule an appointment for the CT.
No food after midnight. Water is okay.
Bring any medications the patient is currently taking.
Discuss possible risk of anesthesia/sedation. A qualified technician working under the direct supervision of a veterinarian will be with the animal throughout the procedure. In spite of monitoring protocols, life-threatening complication are still possible. The overall rate of complications is extremely low but always remains a possibility.
RISKS OF CONTRAST: It is routine to give IV contrast (iohexol) to enhance diagnostic capabilities of the CT scan. Risks are uncommon but include allergic reaction, anaphylaxis, kidney injury, and fluid overload, the latter mostly pertaining to patients with heart disease.

Referring Veterinarian Signature(Required)

Referral Information

Client Information

Pet Information

Anatomic Region of Interest (Check all that applies)

Presenting Complaint/History:

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(701) 478-9299

4491 23rd Ave S.

Fargo, ND 58104

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