CT Outpatient Request Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Clinic Name *Clinic Email *Clinic PhoneVeterinarian’s Name *Veterinarian’s Email *Veterinarian’s Phone *Patient Name *Owner's Name *Owner's Email *Owner's Phone *Species *Breed *Age *Sex *FMFSMNWeight * cost) Clinic Report Relevant Clinical History:Relevant Clinical History: Drag & Drop Files, Choose Files to Upload You can upload up to 5 files. (Please include any attachments or recent blood results, histology etc)Study RequiredNZRadVet Report Required (extra cost) *YESNOStatRoutineContrast (Omnipaque): *By ticking this you consent to NZRadVet administering contrast (Omnipaque) if it is indicated. Please see contrast information below before ticking the box.Contrast (Omnipaque) Omnipaque is an iodine-based contrast agent commonly used during a patients CT. A bolus is administered intravenously during the CT scan which enhances blood vessels, organs, and other tissue which will help with differentiating between different structures within the body. Omnipaque is exclusively excreted via the kidneys. As with any drug - the administration of a contrast agent does have risks associated with it. To help you mitigate these risks we would suggest that the following is performed and included in the history when you submit a CT referral. Blood work – Kidney function Urinalysis – Urine specific gravity (USG) Prior adverse drug reactions When discussing a possible CT referral with your client please ensure that they are informed of the risks associated with the administration of contrast. Would you like us toDiscuss the case/ estimate with referring veterinarian firstContact the owner directly to arrange referralSubmit
