Outpatient CT Referral

Pet’s details

Step 2 of 5

Species*
DogCatother
If other:

Name*

Date of birth (dd/mm/yy) *

Breed *

Sex*
MMNFFNunknown
Is the pet insured?*
YesNounknown

Referring Vet Details

Step 3 of 5

Name of practice*

Practice Telephone Number*

Practice Email*

Name of Referring Vet*

Referral Details

Step 4 of 5

Presenting signs*

Summary of history*

Diagnostic tests already performed, such as radiographs, blood tests etc.*

Is contrast required?*
YesNo
Area(s) to scan*
HeadShoulderElbowCarpus/footPelvis/hipsStifleTarsus/footThoraxAbdomenSpine C1-T2Spine T3-S3
Wessex Veterinary Orthopaedics to invoice the client or referring Practice?*
Invoice clientInvoice referring practice

Attachments

Step 5 of 5

If possible please attach any relevant case history and any additional records, such as radiographs, blood test results etc. Alternatively please email the information to referrals@wessexvetortho.com or tick the box below if you would prefer a member of our team to call your practice to organise the transfer of records.

Upload History and/or x-rays?

Please contact my practice