CT Scanning Referral Form

Submit a referral form for a CT scan

Many thanks for referring to Cornwall Veterinary Referrals. This form is designed to facilitate the referral procedure. A referral letter is not necessarily required to accompany this form and clinical history. If you would prefer to telephone to discuss a case, you are most welcome to do so.

Referring Practice Details

Preferred Contact Method:

Patient Details

Patient Sex:

Is patient neutered:

Client Details

Presenting Problem Details

Diagnostic Images:

Body areas:

Imaging Safety Questionnaire

Heart Disease/Pacemaker:

Renal Disease:

Known adverse reactions to medication:

Surgery within the last 2 months:

Metal fragments/implant any location:


Endocrine disease/bleeding disorder/neoplasia:


Security Question:
Note: By submitting this form you confirm that you are a qualified veterinary surgeon who has obtained consent from the patient's owner to act on behalf of the animal described above; that the owner has given permission for the administration of an anaesthetic/sedative to the above animal at the imaging location together with any other procedures that may prove necessary; and that the owner understands that in the unlikely event of an emergency or where additional pain relief or sedation may be required, the imaging branch will act in the best interests of the patient; that the owner has agreed that they have understood that medicines may be used which are not licensed for use in dogs and cats; and that in the event that you cannot be contacted on the above number, you understand that the imaging branch will act in the best interests of the patient.