UCDVH Diagnostic Imaging Services
UCD Veterinary Hospital, University College Dublin, Belfield, Dublin 4
Tel: (01) 716 6099 Fax: (01) 716 6111 Email: uvh.diagnosticimaging@ucd.ie
CT Request Form for Elective Patients
Referring
Veterinarian:
Practice:
Phone:
Fax:
Email:
Client Name:
Patient Name:
Phone:
Date of Birth:
Species: Dog , Cat , Other (specify):
Breed:
Sex: Female , Female Neutered , Male, Male Neutered 
Colour:
Insured: Yes  No 
Weight(kg):
Check Area/region for CT examination (Note: The requesting Veterinarian is responsible for selecting the appropriate area.)
Area

C1-T2
T3-L3
T3-sacrum
L4-sacrum
C1-sacrum
Lumbosacral Plexus
Area
Nasal Cavity
Skull
Bullae
Brain
Thorax
Pelvis
Abdomen

Area
Carpus
Elbow
Shoulder
Tarsus
Stifle
Hip

L/R
L/R
L/R
L/R
L/R
L/R
Other (please specify)
Please state indications/presenting signs
PTO/…
History (compulsory)
 Sedation or general anaesthesia will be required. Are there any indications for an increased anaesthetic
risk in this animal? Yes  No 
 Please note that animals with an increased anaesthetic risk may require special screening examinations
prior to CT examination.
Diagnostic tests and results to date
 All animals over 8 years of age require a recent complete haematology & biochemistry profile to be
forwarded in advance to the DI unit.
Current Medication (compulsory)
Any prior surgical procedures or pre-existing conditions
Differential diagnosis
Additional Medical History:
 Has the patient ever had an allergy or a reaction to any drug or medication including vaccines?
Yes  No 

If known, what was the medication or vaccine that caused the reaction and when did it occur?

And any treatment given?
To help prevent the spread of infectious diseases, patients must be current on all vaccinations.
ACCOUNTS MUST BE PAID AT TIME OF ADMISSION