Equine CT Referral Form - Animal Imaging

Please fill out the form below as completely as possible and someone will be in touch with you shortly. If you would prefer to fax or email in a PDF feel free to download one by clicking the button below.

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Equine CT Referral

Registered Name
Barn Name
Breed
Gender
Age
Color
Owner's Name
Owner's Phone
Owner's Email
Main Contact (if different than owner)
Main Contact Phone
Main Contact Email
Referring Veterinarian
Veterinarian Contact Phone
Clinic Name
Email Copy of Report to
Fax
Please send any radiographs taken at your clinic for your client's appointment.
Radiographs:
- Sent through DVM insight
- Emailed to info@animalimaging.net
- Sent with client
- None taken
Please check exam your prescribing to this patient.
- CT of Skull / Sinuses
- CT - Foal
Contrast (if indicated)
- Yes
- No
Specific Area of Interest
Symptoms/Clinical Signs
Additional Exam You Are Prescribing?
Please upload any relevant records, labs, and radiographs for this referral.
Drop files here or
Veterinarian's Signature
Veterinarian Certification*
I certify that I am a licensed veterinarian that has performed a physical examination on the aforementioned patient and am submitting this referral on their behalf.
Comments
This field is for validation purposes and should be left unchanged.

Equine CT Referral

Please send any radiographs taken at your clinic for your client's appointment.

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