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Outpatient CT Referral Request Form

This is for a standard CT scan.

To ensure timely scheduling and appropriate patient care, please select the correct CT referral option below. Referrals submitted through the incorrect form or without all required information — including medical notes, laboratory reports, and diagnostic images/reports from the past year — will be returned without scheduling.

Imaging Only

Imaging and Surgical Consult

Imaging & Internal Medicine Consult

Outpatient CT Referral- Imaging Only

Select this option only if you are referring a patient for CT imaging WITHOUT an Internal Medicine or Surgical consultation.

  • Required information needed to be attached: Medical notes, laboratory reports (minimally serum chemistry and urinalysis), diagnostic images (3-view chest x-rays needed on all cases suspected of neoplasia or having a confirmed history of neoplasia), and medical records reports for the last 12 months.

  • Diagnostic CT imaging only

  • Imaging report through VetCT provided to referring provider

  • You, as the PROVIDER then is responsible for calling the owner with the results of the imaging report

  • No Internal Medicine or Surgical appointment scheduled

  • Do NOT select this option if you are requesting medical case management or an Internal Medicine or a Surgical consultation.

  • If you are referring a pet for a head CT and will later want to refer for rhinoscopy, our internists will need to repeat the CT immediately prior to the rhinoscopy, which will result in several CTs being performed on pet. Please consider the Internal Medicine referral for this.

  • If you are referring a pet for surgical planning (mass removal, etc) and will later want to refer for surgery, our surgeons may need to repeat the CT immediately prior to the surgery, which may result in several CTs being performed on pet. Please consider the Surgical referral option for this.

  • If you are referring a pet for a CT to help diagnose an insulinoma, Portosystemic Shunt, or other disease processes that require double or triple phase contrast administration, you must refer through CT with Internal Medicine Consultation.

Fill out form >

Outpatient CT Referral- Imaging and Surgical Consult

Select this option if you are requesting CT imaging WITH a Surgical consultation.

  • Please choose one of the following:

    • Boarded surgeon (DACVS Diplomate only)

    • Residency trained surgeon

    • Non-boarded, non-residency trained DVM with advanced surgical training

    • First available/No preference

  • Diagnostic CT imaging

  • Surgical consultation scheduled

  • Medical interpretation and recommendations provided at Surgical consultation

Important Information:

  • Referrals submitted to the incorrect form or missing required information cannot be scheduled until corrected and will cause a delay for your patients.

  • Selecting the correct referral type and submitting required information helps prevent delays in patient care.

  • Required information needed to be attached: Medical notes, laboratory reports (minimally serum chemistry and urinalysis), diagnostic images (3-view chest x-rays needed on all cases suspected of neoplasia or having a confirmed history of neoplasia), and medical records reports for the last 12 months.

Fill out form >

Outpatient CT Referral- Imaging & Internal Medicine Consult

Select this option if you are requesting CT imaging WITH an Internal Medicine consultation.

  • Diagnostic CT imaging

  • Internal Medicine consultation scheduled

  • Medical interpretation and recommendations provided at IM consultation

Important Information:

  • Referrals submitted to the incorrect form or missing required information cannot be scheduled until corrected and will cause a delay for your patients.

  • Selecting the correct referral type and submitting required information helps prevent delays in patient care.

  • Required information needed to be attached: Medical notes, laboratory reports (minimally serum chemistry and urinalysis), diagnostic images (3-view chest x-rays needed on all cases suspected of neoplasia or having a confirmed history of neoplasia), and medical records reports for the last 12 months.

Fill out form >

Outpatient CT Referral Form

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