Outpatient CT Referral Form
If requesting an outpatient CT study, the requesting clinician will be solely responsible for communicating the results and making treatment recommendations based on the findings. If a consultation with a specialist is desired, then an appointment must be scheduled with a specialist instead of an outpatient CT.
Please complete the form below and upload or email the patients most recent 2 years of medical records, lab work and radiographs when applicable to firstname.lastname@example.org. After review of the submitted information, a CT technician will be in contact for scheduling. Please feel free to call us with any further questions.