CT Referral Form

This form is only for use by veterinary surgeons to arrange outpatient CT. Referral forms for other disciplines, and word versions of referral forms, can be found here.

If you have a pet who you wish to be seen at South Devon Referrals, please contact your veterinary practice and ask them to contact us to arrange referral. We will then contact you to arrange a convenient appointment time.

More information, and pricing details, for our CT service are available here.

You will receive a copy of the online referral by email: if you do not receive this then please contact us by other means to confirm we have received your referral (please check your spam folder).

All items marked with an asterisk (*) are required. Please check they are completed and once you have submitted the form ensure you receive the message “Your message was sent successfully, and we have sent you a copy. Thank you.” which will appear under the submit button.

CT Imaging Request Please ensure that you select every area you wish to be scanned below. If you are unsure of which areas you need to scan, please phone 01626 367972 and ask to speak to one of the CT referral vets for advice.





FORELIMBS:




HINDLIMBS:




Please always phone practice to discuss BEFORE urgent CT referral.

Practice details


Client information

Patient information

MaleFemale

EntireNeutered

History




Heart disease/ PacemakerRenal diseaseKnown adverse reactions to medicationsSurgery within the previous two monthsMetal fragments / implants any locationPregnancyEndocrine disease, bleeding disorder, neoplasiaEpilepsyNone of the above


Upload relevant history or other files

Maximum upload size is 2 Mb per file. If you have larger files to send please email them directly.









NOTE: By submitting this form you confirm that you are a qualified veterinary surgeon who has obtained consent from the patient’s owner to act on behalf of the animal described above; that the owner has given permission for the administration of an anaesthetic/sedative to the above animal at the imaging location together with any other procedures that may prove necessary; and that the owner understands that in the unlikely event of an emergency or where additional pain relief or sedation may be required, the imaging branch will act in the best interests of the patient.; that the owner has agreed that they have understood that medicines may be used which are not licensed for use in dogs and cats; and that in the event that you cannot be contacted on the above number, you understand that the imaging branch will act in the best interests of the patient.

All items marked with an asterisk (*) are required. Please check they are completed and once you have submitted the form ensure you receive the message “Your message was sent successfully, and we have sent you a copy. Thank you.” which will appear under the submit button.