Referring CT Scan Form

Referring your client to Taconic Veterinary Center is easy, just fill out the form below or call us at 914-737-2437.

Referring Veterinarian Information

Referring Veterinarian *

Referring Veterinarian e-mail *

Referring Veterinary Hospital *

Referring Hospital e-mail *

Referring Hospital Phone Number

Referring Hospital FAX Number

Client Information

Client Name

First

Last

Client Email

Client Phone Number

Client Address

City

State

Zip

Patient Information

Patient Name *

Date of Birth / Age

Sex

Male

Female

Is the patient spayed or neutered?

Yes

Species

Breed and color

Indication for CT

Region to be scanned

Include contrast with CT?

Yes

Known concurrent medical conditions

Current medications and doses

Known allergies

Upload medical records and required CBC/Chemistry from the last 30 days *

Maximum file size: 52.43MB

All records need to be sent to Taconic Veterinary Center before the appointment can be scheduled.

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Referring CT Scan Form

Referring Veterinarian Information

Client Information

Patient Information

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