CT Scan Referral Form

This form must be completed by the referring veterinarian, and submitted via email to info@phasesvetemerg.com. Our team will review the referral and contact you to let you know whether it has been accepted. We will then contact your client directly to schedule their scan. Following their scan, the imaging report will be sent back to your clinic for you to share with your clients, unless they have been fully referred into our care through our emergency department.

The form must be filled out IN FULL, to avoid any delays in the referral process. Thank you.

Referring Veterinary Information:
Referral Date:*
Date Format: DD slash MM slash YYYY
Referring Clinic:*
Referring Veterinarian:*
Phone
Email
Client/Patient Information:
Owner Name:*
First Last
Owner Phone:*
Owners Email:*
Patient Name:*
Species:*
Breed:*
Age:*
Sex:*
Patient Behaviour in Veterinary Environment
(Easy to handle?)
Summary of Completed Diagnostics
Tentative Patient Diagnosis:
Reason for CT:
(What are you looking for or trying to answer?)
Specific Areas of Interest that you are wanting scanned
(Please be very specific!)
Current Medications:
(Include dosage, frequency, dates started, include all medication pet is currently taking including supplements, holistic therapy etc.)
Any history of complications from anesthesia or sedation?*
Any previous or other underlying medical issues that you feel our team should be aware of? Any other pertinent information you wish to share with our team?*
Consent
Please discuss the following points with your client PRIOR to referral, and ensure you can answer yes to each:
1) My client is aware that deep sedation or full general anesthesia will be required depending on the type of scan being completed and whether contrast is being administered.
2) My client is aware of the risks of sedation or anesthesia in their pet.
3) My client is aware of the risks of IV contrast administration in their pet.
4) My client is aware they cannot be present for the scan, and that their pet will be dropped o at our hospital to be picked up once they have recovered from their sedation or anesthetic.
5) My client is aware that PVEH will NOT be going over results (unless emergent life threatening findings discovered and your facility is closed when the report returns), and that the radiologist report will be sent back to your clinic for you to review with them, and that this process can take a minimum of 24-36 hours.
6) My client is aware of the costs of a CT scan.
a. You can contact our team to be sent our UTD pricing list for scans and radiologist reports.
Consent of referring DVM:*
By checking this box I give my signature to this form.

24 HOUR EMERGENCY CARE

Contact Info

P: 236-766-0450

E: info@phasesvetemerg.com

1350 Summit Drive
Kamloops, BC, V2C1T8

Hours

Open 24 hours Per Day
7 Days Per Week
365 Days Per Year