C.T. Imaging Referral Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Practice Telephone Number *Referring Practice *Referring Vet *Referring Practice Email *Client Name *FirstLastPatient Name *Patient Species *Patient SexMaleFemaleNot ApplicablePatient Age *Email *Urgent Report Needed (Will affect cost) *NoYes1 Working day2-4 hoursPictures required for surgical planning (vet CT 5 day standard report time) *YesNoPertinent HistoryAnimals weight (kgs)Body Areas *HeadThoraxAbdomen/PelvisC1 – T2T3 – SacrumForelimbsHindlimbsOtherHeart Disease / Pacemaker? *YesNoRenal Disease? *YesNoKnown Adverse Reactions to Medication? *YesNoMetal Fragments / Implants in Any Location? *YesNoPregnancy? *YesNoEndocrine Disease, Bleeding Disorder, Neoplasia? *YesNoEpilepsy? *YesNoIf YES for any of the above questions, please provide further details. Payment optionsJubilee bills client directlyJubilee invoices you the referring practice and you manage payment.Are you happy animal is safe for general anaesthesiaYesNo bloods are required?Email *Send