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Referral Form - Outpatient CT
@
SWAN VALLEY CT
Referring Veterinarian
Referring Practice
Vet's Email
Client's Name
Practice Phone Number
Client's Phone Number
Patient's Name
Breed
Patient Gender
Female Entire
Female Speyed
Male Entire
Male Neutered
Age
Area to CT:
Brief patient summary:
Is this an urgent scan?
Yes
No
Anything else you would like to add?
Attach Clinical History (PDF)
Upload File
Upload supported file (Max 15MB)
Submit Referral