Case Referral Request Form

Referring Doctor Name:*

Referring Hospital Name:*

Today's Date:*

Referring Doctor's Phone Number:*

How would you like to receive the report?*

Email:
Fax:

Patient Name:*

Species:*

Cat

Dog

Other

DOB/Age:*

Breed:*

Sex*

Female

Female Spayed

Male

Male Neutered

Weight:*

All questions are required. If they do not apply, please type or select -N/A.

Tentative Diagnosis/Differentials:*

Current Medications:*

Diagnostics Performed:*

History/Clinical Symptoms:*

CT REFERRAL INFORMATION

Are you referring this patient for a CT scan?*

Yes

Who should we contact to schedule the CT?*

Owner

Veterinarian/Clinic

CT Images Requested

Head & Neck*

Entire Skull

Brain

Sinuses

Other

N/A

Spine:*

C1-T2

T3-L3

L4-Sacrum

Other

N/A

Soft Tissue:*

Thorax

Abdomen

Other

N/A

Limbs & Joints*

Left - Front Limb

Left- Hind Limb

Right - Front Limb

Right - Hind Limb

N/A

If you selected OTHER above, please provide details here.*

OTHER REFERRAL INFORMATION

Are you referring this patient for an Ultrasound?*

Yes

Who should we contact to schedule the Ultrasound?*

Owner

Veterinarian/Clinic

N/A

Ultrasound Images Requested*

Echo

Abdomen - Full

Abdomen - Focus (Please specify below)

Other- (Please specify below)

N/A

If you selected Abdomen-Focus or Other above, please specify here. Otherwise, type N/A.*

Are you referring this patient for surgery?*

Yes

Who should we contact to schedule the surgery/consult?*

Owner

Veterinarian/Clinic

N/A

Why are you referring your patient to Best Friends Animal Hospital and Urgent Care Center for Surgery*

Consult

Orthopedic

Soft Tissue

N/A

ANESTHESIA AND BLOODWORK INFORMATION

Because we sedate patients and administer IV contract (lopamidol), we recommend a basic chemistry panel within 7 days of the scan. Please include bloodwork results. BFAH is able to perform bloodwork prior to the scan if necessary (please check one of the selections below)*

I would like BFAH to perform the bloodwork.

Bloodwork results are attached.

Are there any concerns regarding anesthesia or the use of IV contrast for this patient?*

Yes (If yes, please explain below)

Case Referral Request Form

Referring Doctor Name:*

Referring Hospital Name:*

Today's Date:*

Referring Doctor's Phone Number:*

How would you like to receive the report?*

Patient Name:*

Species:*

DOB/Age:*

Breed:*

Sex*

Weight:*

All questions are required. If they do not apply, please type or select -N/A.

Tentative Diagnosis/Differentials:*

Current Medications:*

Diagnostics Performed:*

History/Clinical Symptoms:*

CT REFERRAL INFORMATION

Are you referring this patient for a CT scan?*

Who should we contact to schedule the CT?*

CT Images Requested

Head & Neck*

Spine:*

Soft Tissue:*

Limbs & Joints*

If you selected OTHER above, please provide details here.*

OTHER REFERRAL INFORMATION

Are you referring this patient for an Ultrasound?*

Who should we contact to schedule the Ultrasound?*

Ultrasound Images Requested*

If you selected Abdomen-Focus or Other above, please specify here. Otherwise, type N/A.*

Are you referring this patient for surgery?*

Who should we contact to schedule the surgery/consult?*

Why are you referring your patient to Best Friends Animal Hospital and Urgent Care Center for Surgery*

ANESTHESIA AND BLOODWORK INFORMATION

Because we sedate patients and administer IV contract (lopamidol), we recommend a basic chemistry panel within 7 days of the scan. Please include bloodwork results. BFAH is able to perform bloodwork prior to the scan if necessary (please check one of the selections below)*

Are there any concerns regarding anesthesia or the use of IV contrast for this patient?*

Please explain any concerns you may have regarding anesthesia or IV contrast for this patient.*