1Veterinarian Information(*) Indicates Required FieldVeterinarian’s Name(Required) First Last Hospital/Clinic Name(Required)Email (for receiving reports)(Required) Phone(Required)2Patient/Owner InformationOwner's Name(Required) First Last Email(Required) Phone(Required)Patient Name(Required)Sex(Required) Female Female Spayed Male Male Neutered UnsureASA Class(Required) I – Normal Healthy Patient II -Mild Systemic Disease III – Moderate Systemic DiseaseSpecies / Breed(Required)Weight (kg)AgeType of Imaging Requested Skull CT Lumbosacral Spine CT Thoracic CT Cervical Spine CT Fluoroscopy Abdominal CT Thoracic Spine CT Pelvic CT Lumbar Spine CT Appendicular Skeleton CT limb or joint3 For patients undergoing anesthesiaPatients must be fit for sedation/anesthesia, ideally CBC & Chem screen of less than 90 days. Only ASA 1-3 patients will be seen. Fear Free Protocol Premedication Recommendations: DogsGabapentin 10–20 mg/kg PO (5–10 mg/kg if geriatric/azotemic)Trazodone 2–5 mg/kg PO CatsGabapentin 5–20 mg/kg PO (2.5–5 mg/kg if geriatric/azotemic)Either Buprenorphine 0.015–0.02 mg/kg TM/SL or Trazodone 12.5–25 mg per catDirect client to give meds 2 hours before (and optionally the night before) the visit.(Required) I have examined the patient on this form and to the best of my knowledge is fit to undergo sedation and/or brief anesthesia. I certify that this patient is not on any medications that could complicate sedation and/or brief anesthesia.SignatureYour NameYour NameYour NameYour NameCAPTCHAΔ
