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 deanparkpet@gmail.com

• Reason For Referral
• Current Concern(s):
• Relevant history, current treatment/medications:

• Please attach all relevant radiographs and labwork.

Please Note: We require you to perform CBC, CHEM and UA, prior to referrals, including T4 in dogs and cats, 7 yrs. & older. Once we receive your fax/email, we will contact the client to arrange their appointment. We will email the final report, from Radterra Radiologists, to the referring hospital which can then be reported to the owner.

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

Cone Beam CT is a recent technology used to aid diagnosis of ear, eye, TMJ, nasal disorders, skull and facial fractures and some neoplasia.

Dean Park Pet Hospital, 1700 McTavish Rd. North Saanich
Fax completed referral form to 250-656-4220
E-mail Us: reception@gmail.com
Phone: 250-656-9911