CBCT Form

• Referring Hospital:

• Veterinarian:

• Date:

• Phone:

• Fax:

• Email:

• Client Information:

• First Name:

• Last Name:

• Address:

• City/Town:

• Postal Code:

• Home Phone:

• Cell/Other:

• E-mail:

• Patient Information:

• Name:

• DOB:

• Sex:MMNFFS

• Species:

• Breed:

• Colour:

• Weight (kg):

• Temperament:GoodNervousMay BiteMuzzle

• Status

• EmergencyUrgentNext Available

• Patient History:

• Has bloodwork been done within the last 6 months?:YesNoSent

• Have chest radiographs been obtained?:YesNoSent

• Have dental radiographs been obtained?:YesNoSent

• Has ultrasound/echo been performed?:YesNoSent

• Has the patient been diagnosed with any of the following?:Heart DiseaseLiver DiseaseSeizureKidney DiseaseDiabetesRespiratory DiseaseNone

• Has the patient shown any of the following clinical signs?:CoughingSneezingVomitingDiarrheaOtherNone

• Please send all radiographs and relevant lab work to reception@deanparkpet.com

• Reason For Referral

• Current Concern(s):

• Relevant history, current treatment/medications:

• Please attach all relevant radiographs and labwork.

Please Note: We encourage you to recommend and perform blood tests prior to CBCT referrals, including T4 in cats 7 years or older. Once we receive your referral we will contact the client to arrange their appointment. We will email the final radiology report (Radterra Radiologists) to the referring hospital which can then be reported to the client.

Heavy sedation or general anesthesia is required for the scan. Please call or email for an estimate

Cone Beam CT is used to aid in the diagnosis of ear and eye issues, TMJ, nasal disorders, skull and facial fractures and some neoplasia.

Dean Park Pet Hospital, 1700 McTavish Rd. North Saanich
E-mail: reception@deanparkpet.com
Phone: 250-656-9911