[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-0-en-105":3,"doc-seo-387312-105":59,"doc-detail-387312-en":131},{"code":4,"msg":5,"data":6},0,"success",[7,13,18,23,28,33,38,43,48,51,55],{"id":8,"doc_module":4,"doc_module_name":9,"category_name":10,"show_sort_weight":11,"slug":12},1,"Document","Story & Novel",90,"story-novel",{"id":14,"doc_module":4,"doc_module_name":9,"category_name":15,"show_sort_weight":16,"slug":17},2,"Literature",80,"literature",{"id":19,"doc_module":4,"doc_module_name":9,"category_name":20,"show_sort_weight":21,"slug":22},4,"Exam",70,"exam",{"id":24,"doc_module":4,"doc_module_name":9,"category_name":25,"show_sort_weight":26,"slug":27},5,"Comic",60,"comic",{"id":29,"doc_module":4,"doc_module_name":9,"category_name":30,"show_sort_weight":31,"slug":32},6,"Technology",50,"technology",{"id":34,"doc_module":4,"doc_module_name":9,"category_name":35,"show_sort_weight":36,"slug":37},7,"Healthcare",40,"healthcare",{"id":39,"doc_module":4,"doc_module_name":9,"category_name":40,"show_sort_weight":41,"slug":42},8,"Research & Report",30,"research-report",{"id":44,"doc_module":4,"doc_module_name":9,"category_name":45,"show_sort_weight":46,"slug":47},9,"Religion & Spirituality",20,"religion-spirituality",{"id":46,"doc_module":4,"doc_module_name":9,"category_name":49,"show_sort_weight":46,"slug":50},"World Cup","world-cup",{"id":52,"doc_module":4,"doc_module_name":9,"category_name":53,"show_sort_weight":52,"slug":54},10,"Lifestyle","lifestyle",{"id":56,"doc_module":4,"doc_module_name":9,"category_name":57,"show_sort_weight":24,"slug":58},19,"General","general",{"code":4,"msg":60,"data":61},"ok",{"site_id":62,"language":63,"slug":64,"title":65,"keywords":66,"description":67,"schema_data":68,"social_meta":124,"head_meta":126,"extra_data":128,"updated_unix":130},105,"en","imaging-referral-form-ct-request-form","Imaging-Referral-Form - CT Request Form","","Outpatient CT request and referral documentation for Institute of Veterinary Specialists, including imaging referral details, patient identifiers, and veterinarian information. Requires general anesthesia for all CT examinations and specifies timing for arrival and submission of the CT request and referral forms at least 48 hours before the appointment. Includes sections for scan region, presumptive diagnosis/rule-outs, report delivery preferences, and patient pre-anesthesia guidance tied to ASA physical status, along with required diagnostic screening and supporting records, radiographs, and lab results.",{"@graph":69,"@context":123},[70,84,106],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/imaging-referral-form-ct-request-form/387312/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/imaging-referral-form-ct-request-form/387312.png","ImageObject",300,407,{"name":92,"@type":93},"percent12345","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-29","2026-09-24",true,{"@type":102,"interactionType":103,"userInteractionCount":105},"InteractionCounter",{"@type":104},"ViewAction",16,{"@type":107,"mainEntity":108},"FAQPage",[109,115,119],{"name":110,"@type":111,"acceptedAnswer":112},"What are the anesthesia and scheduling requirements for CT examinations?","Question",{"text":113,"@type":114},"General anesthesia is required for all CT examinations. Patients must arrive the morning of the scheduled procedure by 8:30am, and the CT Request Form and Referral Form must be received 48 hours prior to the appointment for safe anesthesia planning.","Answer",{"name":116,"@type":111,"acceptedAnswer":117},"What records and imaging should be sent with the referral?",{"text":118,"@type":114},"Send copies of pertinent medical records, radiographs, and lab results. Radiographs and/or images may be emailed, or sent via direct DICOM transfer to the PACS.",{"name":120,"@type":111,"acceptedAnswer":121},"How does ASA physical status affect required pre-anesthesia screening?",{"text":122,"@type":114},"Pre-anesthesia required laboratory tests are determined based on ASA status, following the instruction sheet. Laboratory values should generally be no more than 2 weeks old, and ASA 4 or 5 will require referral to IVS.","https://schema.org",{"og:url":83,"og:type":125,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":127,"canonical":83},"index,follow",{"doc_id":129,"site_id":62},387312,1790787767,{"code":4,"msg":5,"data":132},{"doc_id":129,"user_id":133,"nickname":92,"user_avatar":134,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":135,"file_id":136,"file_url":137,"file_type":138,"file_size":139,"view_count":105,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":81,"language":140,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":67,"update_tm":144,"read_time":39,"preview_page_count":4},1099529851338,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","| Institute of Veterinary Specialists | Outpatient Imaging Services Phone: 352-331-4233\u003Cbr>Fax: 352-331-9328\u003Cbr>Email: [contact@vetheart.com](contact@vetheart.com) |  |\n| --- | --- | --- |\n| ASA Physical Status Reference Chart |  |  |\n|  |  |  |\n| American Society of Anesthesiologists Physical Status Classification\u003Cbr>ASA DESCRIPTION EXAMPLES 1 Excellent Apparently healthy\u003Cbr>• No obvious signs of disease • Periodontal disease stage 1\u003Cbr>• Hip dysplasia 2 Good Mild systemic disease\u003Cbr>• Neonatal or geriatric animals • Compensated cardiac disease\u003Cbr>• Small odontogenic tumors 3 Fair Moderate systemic disease\u003Cbr>• Activity effected or limited • Mild to moderate fever\u003Cbr>• Mild to moderate anemia\u003Cbr>• Diaphragmatic hernia\u003Cbr>• Controlled seizures with other neurological signs\u003Cbr>• Anorexia\u003Cbr>• Cachexia\u003Cbr>• Mitral insufficiency\u003Cbr>• Chronic cardiac disease/newly found\u003Cbr>• Moderate dehydration or anorexia 4 Poor Severe systemic disease\u003Cbr>• Constant threat to life • Shock\u003Cbr>• Sepsis\u003Cbr>• Severe anemia\u003Cbr>• Uncontrolled diabetes\u003Cbr>• Severed dehydration/ hypovolemia\u003Cbr>• Decompensated cardiac or renal disease\u003Cbr>• Emaciation\u003Cbr>• Severe pulmonary disease 5 Guarded Moribund patient\u003Cbr>• Not expected to survive 24 hours without the procedure • Multisystem failure\u003Cbr>• Major trauma\u003Cbr>• Profound shock\u003Cbr>• Severe head injury\u003Cbr>MINIMUM REQUIRED DIAGNOSTIC SCREENING\u003Cbr>ASA \u003C6 years old >6 years old 1,2 • PCV, Chem 10 (past 6 months)\u003Cbr>• ECG\u003Cbr>• IV Catheter (depending on protocol, procedure, etc. ) • CBC, Chem 17 (past 6 months)\u003Cbr>• ECG\u003Cbr>• IV Catheter (depending on protocol, procedure, etc. ) 3,4,5 • Radiographs\u003Cbr>• CBC, Chem 17 (past 6 months)\u003Cbr>• ECG\u003Cbr>• IV Catheter with fluids (depending on protocol, procedure, etc. ) • Radiographs\u003Cbr>• Echocardiogram\u003Cbr>• CBC, Chem 17 (past 6 months)\u003Cbr>• ECG\u003Cbr>• IV Catheter with fluids (depending on protocol, procedure, etc. )\u003Cbr>T4: add this for all cats over 6 years of age Complete profile should include electrolytes |  |  |\n\n\n| Institute of Veterinary Specialists\u003Cbr>\u003Cbr>REFERRAL FORM\u003Cbr>5609 SW 64th Street\u003Cbr>Gainesville, FL 32608 Date:   |  |  | Phone: 352-331-4233\u003Cbr>Fax: 352-331-9328\u003Cbr>Email: [reception@vetheart.com](reception@vetheart.com) |  |  |\n| --- | --- | --- | --- | --- | --- |\n|  |  |  |  |  |  |\n| Patient Name: |  | IVS Patient ID: |  |  |  |\n| Breed: | Age: | Sex: |  | Weight: |  |\n| PLEASE SEND COPIES OF PERTINENT MEDICAL RECORDS, RADIOGRAPHS, AND LAB RESULTS |  |  |  |  |  |\n| Reason for Referral: |  | Radiographs and/or images may be emailed or alternatively a direct DICOM transfer to our PACS. E-mail [contact@vetheart.com](contact@vetheart.com) to set up. |  |  |  |\n|  |  | No images DICOMEmailed | |  |  |\n| Vaccination Status: Canine DA2P:   Feline FVRCP:   Rabies: 1 yr 3 yr  \u003Cbr>Date Given Date Given Date Given\u003Cbr>Medical reason for precluding rabies vaccination (if any): |  |  |  |  |  |\n| Animal Temperament: |  |  |  |  |  |\n| Pertinent History: (Please fax or email a copy of medical history pertaining to admitting complaint) |  |  |  |  |  |\n| Pertinent Lab Results: (Please send a complete copy of results and reference intervals from any lab)\u003Cbr>No labs Emailed Faxed |  |  |  |  | |\n| Current Medication/Treatment: (If complex/ongoing condition, please send medical records showing meds/treatment)\u003Cbr>CLINIC USE ONLY |  |  |  |  |  |\n| Referring Veterinarian:\u003Cbr>First Last |  |  | Appointment Date: |  |  |\n|  |  |  | Appointment Time: |  |  |\n| Veterinary Clinic: |  |  | Estimate Given: $\u003Cbr>yes no |  |  |\n| Address: |  |  |  |  |  |\n| City: State: Zip: |  |  | Communication with: |  |  |\n| Phone: Fax: |  |  |  |  |  |\n| E-Mail: |  |  |  |  |  |\n\n*Must be completed by referring veterinarian and faxed or emailed prior to appointment.  \n[reception@vetheart.com](reception@vetheart.com) 352-331-4233 ph 352-331-9328 fx [www.vetheart.com](www.vetheart.com)  \n(Internal Use Only) PATIENT STICKER HERE  \nInstitute of Veterinary Specialists  \nOutpatient Imaging Services  \nC","cbCaiazTt9vLTmuu","https://ap.wps.com/l/cbCaiazTt9vLTmuu","pdf",573617,"English","# Outpatient Imaging Services - Referral Form\n## Patient and referral requirements\n# CT Request Form\n## General information and anesthesia requirements\n## Referring veterinarian information\n## CT scan requested\n## CT report delivery\n## Patient information and pre-anesthesia tests","[{\"question\":\"What are the anesthesia and scheduling requirements for CT examinations?\",\"answer\":\"General anesthesia is required for all CT examinations. Patients must arrive the morning of the scheduled procedure by 8:30am, and the CT Request Form and Referral Form must be received 48 hours prior to the appointment for safe anesthesia planning.\"},{\"question\":\"What records and imaging should be sent with the referral?\",\"answer\":\"Send copies of pertinent medical records, radiographs, and lab results. Radiographs and/or images may be emailed, or sent via direct DICOM transfer to the PACS.\"},{\"question\":\"How does ASA physical status affect required pre-anesthesia screening?\",\"answer\":\"Pre-anesthesia required laboratory tests are determined based on ASA status, following the instruction sheet. Laboratory values should generally be no more than 2 weeks old, and ASA 4 or 5 will require referral to IVS.\"}]","Imaging-Referral-Form - CT Request Form | PDF",1790284962]