Outpatient CT Referral Form

Thank you for choosing Lucks Lane Veterinary Clinic. Please fill out the form below and our Medical team will reach out for scheduling.

Please Note:

- Critical patients must be stable before we can proceed with a CT.

- Each patient needs a Physical Exam, CBC/Chemistry/UA prior to their arrival (CBC/Chem panels NOT REQUIRED for very small exotic species). Please attach lab results and radiographs or ultrasounds below if available. Do not hesitate to contact us should you have any specific questions.

- All scans will be read by a Board Certified Radiologist or a Veterinarian that is Board Certified in Zoo Medicine (for exotics) within 24 hours. Stat read available.

- After review of the submitted information, a CT technician will be in contact with the client for scheduling within 1-2 business days. Please feel free to call (804) 594-3545 or email frontdesk@llvet.com with any questions.

Client Name

First Name

Last Name

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client Cell Phone

(###)

###

####

Client Home Phone

(###)

###

####

Client Email

Pet's Name

Species

Breed

Breed of pet. If unknown, please leave blank.

Color

Sex

Age

Veterinary Clinic

Referring Veterinarian

First Name

Last Name

Clinic Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Clinic Phone Number

(###)

###

####

Clinic Email

Reason for Referral (Chief Complaint)

Medical History / Clinical Signs

Current Medications / Therapies

Current on Vaccines

Select all that apply.

Rabies

DA2PP

Bordetella

FVRCP

Rabies Vaccine Date

YYYY

Patient's Current Weight

Stat Read Available (+$100)

<2 hour turnaround on results. Additional $100 charge.

Stat Read

Region of Interest for CT Scan

If Extremities, Please Specify

IMPORTANT NOTES

- It is very important to note that your patient will be anesthetized for the CT. Please advise your clients as to the risks of anesthesia, as well as any special instructions regarding medications to be given the morning of the CT/Anesthesia. - Critical patients must be stable before we can proceed with a CT. - Each patient needs a Physical Exam, CBC/Chemistry/UA prior to their arrival (CBC/Chem panels NOT REQUIRED for very small exotic species). Please attach lab results and radiographs or ultrasounds below if available. Do not hesitate to contact us should you have any specific questions. - All scans will be read by a Board Certified Radiologist or a Veterinarian that is Board Certified in Zoo Medicine (for exotics) within 24 hours. Stat read available. - After review of the submitted information, a CT technician will be in contact with the client for scheduling within 1-2 business days. Please feel free to call or email with any questions. 804-594-3545. frontdesk@llvet.com