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Referring Veterinarians
- CT Referral Form

Big Country Veterinary Clinic

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Appointment

(325) 692-2625

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CT Referral Form

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Referring DVM Information

Referring DVM

Clinic

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred Contact

Phone

Fax

Office

Fax

Client Information

Client Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Patient Name

Species

Canine

Feline

Neutered

Yes

Age

Breed

CT Scan Options

Dental CT

Extremity

Skull

Spine

Pelvis

Thorax

Abdomen

Other

Extremity

Small

Medium

Large

If other, please explain

Exam & Consultation at BCVC?

Yes

Patient History Information

Patient History

Diagnostic tests (Please attach all relevant labwork, radiographs) *performed within the last 2 weeks*

Max. file size: 2 GB.

Presumptive Diagnosis:

Medications:

Pertinent Anesthetic/Surgical History:

Known Drug Allergies? Implants? Microchip?

Other Options

CT Scan consult/Antech review

No consultation

Provide USB drive

Big Country Veterinary Clinic

Phone: (325) 692-2625
2426 Industrial Blvd.
Abilene, TX 79605

Business Hours

Mon, Tue, Thu, Fri: 7:00 am–9:00 pm
Wed: 7:00 am–6:00 pm
Sat–Sun: Closed

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