test-it Referring Entity Clinic Name Referring Veterinarian Clinic Phone* Today’s Date Email Address* Owner & Patient Information Owner First Name* Owner Last Name* Phone* Secondary Phone Patient Name* Patient Age* Weight* Sex* Neutered MaleSpayed FemaleMaleFemale Breed* Additional Patient Information Patient History UltrasoundAbdominalEchocardiography (heart only) Do you recommend sedation based on patient history? YESNONOT SURE Computed Tomography (CT-Scan) Head and neckAbdomenPelvisThoraxSpineExtremities CT-SCAN CONTRAST MEDIA ADMINISTRATION CONSENT You must check YES to consent. YES, I consent to CT-SCAN Contrast Media Administration (Additional Charges may apply) Assessment Information For a complete assessment, please send any recently performed imaging including radiographs with the patient regardless of desire for radiographic consultation. For CT imaging with contrast please include recent (within 6 months) blood work including renal profile. Preliminary ultrasound results may be available the same day and radiology consultation for both ultrasound and CT are typically available within 24-48 hours. Attachments Attach File 1 (Max 2MB ) Attach File 3 (Max 2MB ) Attach File 2 (Max 2MB ) Attach File 4 (Max 2MB ) Collin County Veterinary Imaging Center / 5353 Independence Pkwy. Ste. 100 / Frisco, TX 75035P: (469)795-9142 F: (469)795-9143 / Email: info@ccvic.us / Website: www.ccvic.us 66221
