Imaging Referral To refer a patient, please complete our referral form below. Please note we only accept referral patients with ASA I - ASA III classification. Imaging Referral Request Forms Advanced Imaging Request Advanced Imaging Request Veterinarian Information Veterinarian’s Name * Hospital/Clinic Name * Email (for receiving reports) * Phone * Patient / Owner Info Owner's Name * Owner's Name First First Last Last Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Email * Phone * Patient Name * Sex * Female Female Spayed Male Male Neutered Unsure Species / Breed * Weight (kg) Age Type of Imaging Requested Skull CT Thoracic CT Abdominal CT Pelvic CT Appendicular Skeleton CT limb or joint Cervical Spine CT Thoracic Spine CT Lumbar Spine CT Lumbosacral Spine CT Fluoroscopy If Fluoroscopy area, please tell where If you are human, leave this field blank. Next Sedation/Anesthesia Request Form Sedation Consent Form Name * Name First First Last Last Email * Phone * Patient Name * Species * Dog Cat Bird Small Mammal Reptile Amphibian Fish Sex * Male Male/Neutered Female Female/Spayed Unsure Today’s procedure(s) * When did the patient last eat? * In the devastating event that your pet were to deteriorate and experience a cardiac or respiratory arrest, our standard procedure would be to initiate CPR. Please note that costs of this can range from $150-300 per 15 minute session depending on nature and duration of intervention. Under certain circumstances the veterinarian may recommend that resuscitation not be performed; as a pet owner you may prefer not to have resuscitation performed. In such cases you have the option to elect a Do Not Resuscitate (DNR) order. Please note that recovery rates after CPR under anesthesia are better than rates after CPR due to illness or trauma. * Yes, I do wish to have CPR performed No, thank you. If my pet passes away please do NOT resuscitate him/her By checking the boxes below you grant permission for Exotic Vet Care (EVC) to perform the recommended service(s) and fully acknowledge and accept risks associated with sedation/anesthesia. * I, the undersigned owner or agent of the pet identified above, authorize the staff of EVC to sedate/anesthetize my pet. Some risks always exist and I am encouraged to discuss any concerns I have about those risks with the attending veterinarian before the procedures are initiated. While accepting that all procedures will be performed to the best of the abilities of the staff at EVC, I understand that no guarantee or warranty has been made regarding the results that may be achieved. I assume full responsibility for any additional expenses incurred after the sedated/anesthetized procedure is performed. I have read and fully understand the terms and conditions set forth. Signature * signature keyboard Clear Date * Captcha Submit If you are human, leave this field blank.
