CT Referral Form

Thank you for choosing Brilliant Veterinary Care as your preferred New York City veterinarian. Please fill out the following form as thoroughly as possible. If you have any questions, please feel free to call us at 212-365-5160.

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CT Referral Form

For referring veterinarians only. Clients interested in booking a CT should click the following link.

Please Note: All * fields are required

Enter Veterinary Office Email *

Veterinary Office Phone *

Pet Name *

Pet Owner Name *

First

Last

Owner Contact Number *

Owner Email *

Anatomical area of interest? *

Do you want contrast? *

With Contrast
Without Contrast

Upload Pet History (Maximum file size allowed: 10MB)

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Drag and drop files here

Laboratory Results (Maximum file size allowed: 10MB)

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Drag and drop files here

Recent Radiographs (Maximum file size allowed: 10MB)

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Drag and drop files here

History of pet's referred condition, current medications, treatments, previous diagnostics* *

CT Referral Form

CT Referral Form

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CT Referrals

Community care catered to our patient’s needs.

We look forward to seeing you soon!

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