Advanced Imaging Referral Form

Advanced Imaging Referral Form

Please fill in the information below to submit a request.
Referring Clinic / Hospital
Referring Veterinarian*

First NameLast Name
E-mail*
Client Name*

First NameLast 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*

HaematologyBiochemistryUrinalysisBiopsy informationComing with ownerEmailFaxedNot doneOther
Please upload any relevant laboratory results / data

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Previous Imaging*

Radiograph(s)Ultrasound reportComing with ownerEmailFaxedNot doneOther
Please upload any relevant imaging

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Outpatient Service Request
Region(s) of interest

BrainNoseOrbitAuditory CanalsCraniofacialNeckThoraxAbdomen - LiverAbdomen - KidneysAbdomen - BladderAbdomen - Ureter(s)Abdomen - UrethraSpine - CervicalSpine - ThoracolumbarSpine - LumbosacralExtremity (Specify limb(s) and region(s) in Others)Other
Study (where applicable)

PlainIntravenous contrastMyelogramContrast angiogramIntravenous pyelogramOther
Interpretation of results*

Required(additional fees apply)Not required (image DVD will be handed to owner on discharge)
Confirm Submission
Signature

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Date*

DayMonthYear
Should be Empty:

Outpatient Service Request