CT Facility Rental Form

Equipment included:

CT Machine and 3d imaging Vitrea workstation
Anesthetic machine
Hospital oxygen
ECG monitor
Suction pump
Crash cart

Notes

Facility is available Monday - Friday, 9am-5pm,Satauday 10-5pm
Rental charges are for 90 minutes, one patient only
Additional time and materials will be charged seperately
Weekends available as resources are available and will incur an additional out-of-hours charge
A technician will be provided to run the machine, process images, and provide general support for the equipment
We recommend using the (Omnipaque 300mg I/ml)body weight (kg) x 2, to ensure the quality of the CT report. Contast can be provided at an additional charge.
Dicom images will be available for your clinic the same day
Medication ,contrast and comsumables are available at a 15% discount

Clinic Name*

Clinic Phone*

Please enter a valid phone number.

Clinic Email (VSI will release an image link to this address )*

example@example.com

Doctor First Name

Doctor Last Name

Patient Name

Species

Breed

Weight

Body Sites to be included (This will help us plan for the scan)

I understand that this contract is for facility and equipment rental only.*

AgreeDisagree

I understand that VSI will not provide any medical advice or deliver any medical care to the patient.*

AgreeDisagree

The doctor listed above is solely responsible for the health and well being of the patient. Any diagnostics, treatments or procedures performed will be managed by that doctor.*

AgreeDisagree

VSI medical staff, at their sole discretion, can stop any procedure they believe to be unsafe or not in the best interest of the patient.*

AgreeDisagree

The clinic above is financially responsible for any charges incurred, including any damage to equipment from misuse.*

AgreeDisagree

Doctor Signature

CT Facility Rental Form

Clinic and Doctor Information

Patient Information

Release