Please fill out this form and fax to our office. Your client may call our CT technicians directly for scheduling.

Referring Hospital Info

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  1. Client Info











  2. Area to be scanned

  3. Minimum Required Diagnostic Screening:


    CBC/Chem





  4. Anesthetic Risk Classification (ARC)
    Adapted from the American Society of Anesthesiologists Physical
    Status Classification

    ARC

    DESCRIPTION EXAMPLES

    1

    EXCELLENT

    Apparently healthy

    No obvious signs of disease

    Hip dysplasia, OCD lesions, Biceps tendonitis

    2

    GOOD

    Mild systemic disease

    Neonatal or geriatric animals

    (< 8 weeks or > 10 years)

    Vestibular disease, Stifle injuries, Epistasis, Controlled seizure, Compensated cardiac disease

    3

    FAIR

    Moderate Systemic Disease

    Limited activity

    Low or moderate fever, Anorexia, Pneumothorax, Diaphragmatic Hernia, Mild to moderate anaemia, Moderate dehydration & Hypovolemia

    4

    POOR

    Severe Systemic Disease that is a constant threat to life Shock, High fever, Sepsis, Uremia, GDV, DIC, Severe Dehydration & hypovolemia, Uncontrolled diabetes, Severe pulmonary disease

    5

    GUARDED

    Moribund Patient

    Not expected to live past 24 hrs

    Multisystem failure, Major, trauma, Profound shock, Severe head injury

  5.  





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