Computerized Tomography (CT) Referral Form

When referring your patient to our hospital, please complete this form along with all pertinent medical records. If you have any questions while completing this form, please reach out to us at 204-452-0911 or send an email to info@bridgwatervethospital.ca.


 

REFERRING HOSPITAL INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

caution, nervous, etc.

PATIENT HISTORY

REQUESTED SERVICES

CT Requested (Check all that apply) *
Would you like a CSF Tap for this patient at the time of the CT scan? *

All patients require pre-anesthetic bloodwork performed within one month of the CT appointment. If this has not been performed at your hospital, it will be performed prior to the procedure at Bridgwater Veterinary Hospital.

 

Security Question *