Advanced Imaging Referral Form
Please fill in the information below to submit a request.
Referring Clinic / Hospital
Referring Veterinarian
*
First Name
Last Name
E-mail
*
Client Name
*
First Name
Last Name
Client Contact No
*
Patient Name
*
Species
*
Breed
*
Age/DOB
*
Weight
*
Presenting Problem / Tentative diagnosis
Case history / Summary of physical examination findings
Current treatment(s) (including medications and dosages)
Please state any concerns regarding general anaesthesia
Laboratory results / data
*
Haematology
Biochemistry
Urinalysis
Biopsy information
Coming with owner
Email
Faxed
Not done
Other
Please upload any relevant laboratory results / data
Browse Files
Cancel
of
Previous Imaging
*
Radiograph(s)
Ultrasound report
Coming with owner
Email
Faxed
Not done
Other
Please upload any relevant imaging
Browse Files
Cancel
of
Outpatient Service Request
Region(s) of interest
Brain
Nose
Orbit
Auditory Canals
Craniofacial
Neck
Thorax
Abdomen - Liver
Abdomen - Kidneys
Abdomen - Bladder
Abdomen - Ureter(s)
Abdomen - Urethra
Spine - Cervical
Spine - Thoracolumbar
Spine - Lumbosacral
Extremity (Specify limb(s) and region(s) in Others)
Other
Study (where applicable)
Plain
Intravenous contrast
Myelogram
Contrast angiogram
Intravenous pyelogram
Other
Interpretation of results
*
Required(additional fees apply)
Not required (image DVD will be handed to owner on discharge)
Confirm Submission
Signature
Date
*
-
Day
-
Month
Year
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