Referral Form

Referral Typed(Required)

Routine

Stat

CT Scan

Ultrasound

Referring Clinic Information

Clinic Name(Required)

Referring Veterinarian(Required)

Phone(Required)

Fax

Email(Required)

Preferred method of communication

Phone

Email

Fax

Client Information

Name(Required)

First Last

Phone(Required)

Email(Required)

Contrast Required?

Select one(Required)

Yes

No

At Lifetime Animal Hospital Discretion

Anesthesia / Sedation / IV Contract Concerns:

Are there concerns for any of these practices?(Required)

Yes

No

Lifetime Animal Hospital in most cases will sedate for CT Scanning in order to capture ideal image) If yes please list known risks, medications, or concerns:

Because we sedate patients and administer IV contrast, we require a basic chemistry panel within seven (7) days of the scan. Please include bloodwork results. Lifetime Animal Hospital is able to perform bloodwork prior to the scan if necessary.(Required)

Bloodwork results are attached

Please perform required bloodwork

Additional Requests

Radiologist interpretation report

Image copy for referring vet

Other Notes

Referring Clinic Information

Client Information

Patient Information

Area Requested for CT

Contrast Required?

Anesthesia / Sedation / IV Contract Concerns:

Contact Us

Clinic Hours

Emergencies

Online Store

Referral Form

Referring Clinic Information

Client Information

Patient Information

Area Requested for CT

Contrast Required?

Anesthesia / Sedation / IV Contract Concerns:

Contact Us

Clinic Hours

Emergencies

Online Store

Veterinary CT Scanning for Northwest Wyoming Coming in March 2026!