CT Referral Form
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CT Referral Form

Patients undergoing general anesthesia (approximately 1.5-2 hours) will have a physical exam and bloodwork consisting of: CBC, PCV/TS and Chemistry Panel. If available, please send lab results with this referral form; labs can be completed here at SEMC if none are provided. All shoes will need to be pulled for limb scans. Shoes may be removed at SEMC if not done prior to arrival. *Limb scans are offered to trained horses only.*

Send all labs and previous records and radiographs to: office@saladoemc.com

It is strongly recommended to drop off by 5 PM the day prior to the appointment. If this is not feasible, please arrive no later then 8 AM the day of. Due to the uncertainty of imaging time, it is likely that the patient may need to stay overnight. A call the the Primary Contact will be made when the patient is ready to be discharged. 

Please fill out the form below

Owner Name(Required)
Owner Phone Number(Required)
Owner Email(Required)
Primary Contact
Contact Phone Number

Referring Veterinarian Information

Referring Veterinarian/Clinic(Required)
RDVM Phone Number
DVM to receive case

Patient Information

Patient Registered Name(Required)
Nickname
Date of Birth(Required)

Insurance Information

Insured?
Insurance Company
Contact Name
Contact Phone Number
Company Notified?

Case Information

Previous Radiographs
Previous Ultrasounds
Previous CT or MRI
CT Selection