CT Request

Approximate costs associated with a scan	Standard Price
CT Scan (1 area) with Interpretation Report and with Contrast	£1250
Extra area	£250
Urgent report (within 4 hours)	£217 extra
Priority report (within 24 hours)	£134 extra
Enhanced report (within 1 – 2 days)	£91 extra

Outpatient Imaging Request Form

Practice Details

Date:

Referring Vet:

Referring Practice:

Practice Address Line 1:

Practice Address Line 2:

Practice City:

Practice Postcode:

Practice Email:

Practice Telephone Number:

Client Details

Client Title:

Client First Name:

Client Surname:

Client Address Line 1:

Client Address Line 2:

Client City:

Client Postcode:

Client Primary Contact Number:

Client Secondary Contact Number:

Patient Details

Patient Name:

Patient Species:

Patient Breed:

Patient Age:

Patient Sex:

Patient Weight:

Has the patient been neutered?:

Yes
No

Has the patient been imported from outside of the United Kingdom?:

Yes
No

If YES, have they been tested for Brucellosis?:

Yes
No

Insurance Details

Is the patient insured?:

Yes
No

Insurance Company:

Policy Number:

Policy Limit Amount:

Has a direct claim been requested?:

Yes
No

Please ask your client to speak to their insurance company and give permission for Rowe Referrals to speak to them to confirm/discuss details of their insurance policy on their behalf.

Referral Details

Urgency of the Case:

Urgent
Priority
Enhanced
Routine

Date of onset of clinical signs:

Presenting Signs:

Clinical Examination:

Other test results and current medication (attach further history if needed):

A contrast agent is typically used when scanning. Is contrast required?:

Yes
No

Have pre-operative bloods been performed prior to admission?:

Yes
No

Attachments

Please attach the appropriate case history and any additional records e.g. test results, radiographs, ECG tracings etc (Max total file size 8MB).

Attach Animal History (Optional):

Security Question:

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