CT Scan Request

Please complete and submit this form to request a CT Scan for your pet. You will need to fax or email recent bloodwork as well.

Please note that this is only for our Vienna location.

Referring Veterinarian Information
Client and Patient Information (Required)
Please indicate patient history including past and current medical problem(s), results of all diagnostic testing, any medication(s), and response to medication, if any. This is how the information for the radiologist request will appear. Please include any sensitivity to anesthesia or any known allergies.
Scan Information
CT Image Request
If renally compromised and receiving contrast, half dose of contrast is recommended.