Out Patient CT Referral Form

READ AND COMPLETE THE FOLLOWING PRIOR TO SENDING THE FORM

• Contact CVMG to review the case and ensure that the case qualifies for an outpatients CT.

• Upload (or send via email or fax) available medical records and diagnostics to CVMG (Lab work that has been done within 30 days of the CT scan can be used as pre-anesthetic bloodwork).

• If we do not receive this Out Patient CT Referral Form prior to the scheduled appointment, we will be unable to perform CT scan.

Owners should anticipate that their pet may need to stay at Countryside Veterinary Medical Group for the day.

Patients need to be fasted 12 hours prior to appointment. You will be sent the CT results within 24 hours. If you decide you would like to have a consult with one of our specialist, please let us know and we will accommodate any additional needs.

Quicklinks

CLICK ON ICON TO DOWNLOAD FORM