CT Referral Form | Lubbock Small Animal Emergency Clinic, TX

Referring a Patient for a CT scan?

Help us provide the best care—fill out the form below to refer your patient for a CT scan.

Date of Referral(Required)

Referral Clinic(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Clinic Phone(Required)

Name of Doctor(Required)

First Last

Email for Radiologist Report(Required)

Doctor Phone Number(Required)

Client Name(Required)

First Last

Client Phone #(Required)

Patient Name(Required)

Patient DOB

Sex(Required)

Spayed or Neutered(Required)

Spayed

Neutered

Neither

Breed(Required)

Scan Requested(Required)

Skull/Dental/Sinuses

Thoracic

Abdomen

Spine (cervical, thoracic, lumbar)

Patient History

Diagnosis(Required)

Notes to the Radiologist(Required)

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