Radiology for Pets
Imaging Request Form
Date of study
*
-
Day
-
Month
Year
Date the study is to be performed (or was performed).
Hospital
*
Please Select
ARHC
ARH Essendon Fields
ARH Fairy Meadows
ARH Homebush
CAS
CCVC
ECA
GWAH
GXSTAH
MEDIPAWS
MOUNT PLEASANT VETERINARY GROUP
NARWEE VET HOSPITAL
NSVH
NQ CARE
ONE PET CANCER CARE
ORCA
RSPCA
SASH Alexandria
SVES
SYDNEY PET DENTISTRY
THE PET SPECIALISTS
THE UNUSUAL PET VETS
UVTHS
UVTHC
VECA
VDC
VETS ON CROWN
VSOS
VET VISION
OTHER PRACTICE
Patient ID
*
Please ensure correct patient ID.
Patient name
*
Name
Last Name
Age
Age
Sex
Please Select
Female (Entire)
Female (Neutered)
Male (Entire)
Male (Neutered)
Unsure
Species
Please Select
Canine
Feline
Equine
Lapine
Reptile
Other
Breed
Breed
Weight (KG)
Imaging request
Acquisition
Report
Second opinion
Is this a follow up study?
Yes
No
Modality(s)
*
CT
Echo
Fluoroscopy
MRI
Scintigraphy
Radiography
Ultrasound
What type of sample?
Biopsy
FNA
Centesis
Cystocentesis
Other
Consent for samples to be collected at time of study?
Yes
No
Other
Does {patientDetails} have a history of CKD, hypertension, possible pheocromocytoma and/or multiple myeloma.
Region of Interest
*Head, neck, thorax, left carpus, full body etc.
Study
E.g. cholangiography, arthrography, sub-flush, GIT, thyroid, hepatobiliary, etc. If not sure leave it blank
Previous relevant imaging available. Please note if at a different institution.
If previous reports available please attach below.
File Upload
Browse Files
Drag and drop files here
Choose a file
Previous imaging report, pathology reports, relevant jpeg imaging studies for review and/or videos (e.g. neurological patients)..
Cancel
of
Relevant Clinical History/Clinical Signs/medication
* Please do not copy/paste the full patient history. * Oncological patient consider chemo and/or radiation. dose/drug, starting and finish treatment day alternatively when was the last day of treatment. * Surgical cases-procedure, date performed or time progression, mention progression of the patient if applicable, any previous complications.
Questions to be answered
*
Current/Recent medications
*Any medication given or discontinued within the last 7 days.
Sedation Protocol used/to be used
Clinician Name
*
First Name
Last Name
Clinician E-mail
*
example@example.com
Phone Number
Format: 00 0000 0000.
Report turn around times:
*
VERBAL STAT - Phone call and discussion within 1hr. This option can incur a delay on written report (additional fees).
24-hour Urgent read - Written report 24 hour turn around (additional fees).
Standard turn around - Written report (no additional fees).
Sedation Protocol used/to be used
Acepromazine
Alfaxalone
Alfentanil
Buprenorphine
Butorphanol
Fentanyl
General Anaesthesia (Isoflurane)
Ketamine
Medetomidine
Methadone
Midazolam
Morphine
Propofol
Unknown
Zoletil
Other
Skype contact
name of the Skype contact or email of the account
SUBMIT
Should be Empty: