BEECROFT OUTPATIENT REQUEST FORM
Note: All interpretation results will be sent to referring vet directly. We will not be discussing any result with the pet owners for outpatient imaging
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PATIENT & REFERRING VET DETAILS
Submission Date
*
-
Day
-
Month
Year
Date
Name Of Referring Vet
*
Clinic Name
*
Referring Vet Contact
*
Email Address For Correspondence and Confirmation
Patient Name
*
Owner's Name
*
Owner's Email
*
Owner's Contact
*
Species/Breed
*
e.g. Feline/DSH, Bird/Cockatoo, Rodent/Chinchilla
Age
*
e.g. 3Y2M
Sex
*
Male
Female
Unknown
Neutered
*
Yes
No
Unknown
Is this urgent?
*
Yes
No
Upload History And Relevant Imaging Records
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Outpatient Imaging Services
Services Required
*
MRI (Specialist-to-Specialist referral only)
CT Scan
Ultrasound
Scope (may require consultation)
Other
Specify Scope site:
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MRI
Indicate Region
*
Require interpretation?
*
Yes
No
Pertinent history and clinical questions petaining to the scan
*
ASA score:
*
CT Scan
Indicate Region (Hold Ctrl and click to make multiple regions selections)
*
Head
Thorax
Abdomen
Shoulder
Elbow
Carpus/Foot
Stifle
Tarsus/Foot
Spine C1 - T2/Neck
Spine T3 - L7/S1
Pelvis/Tail
Require interpretation?
*
Yes
No
Interpretation Urgency (Skip If Standard Turnaround)
*
2 working days
24 Hours
4 Hours
Pertinent history and clinical questions petaining to the scan:
*
Ultrasound
Indicate Region
*
Please Select
Abdominal
AFAST/TFAST
Double Cavity
Focal
Thyroid/Parathyroid
Thorax
Muscoskeletal
Ocular
For abodominal ultrasounds, the owner has been communicated with and understands the need for sedation.
*
Yes
Not applicable to my patient
Echocardiogram
*
Yes
No
Pertinent history and clinical questions petaining to the scan:
*
Additional Request
Additional Request
FNA
Biopsy
Urine
Labarotory
Specify Additional Request Needed
TTO CDP ID
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