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 (Iopamiro 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
If send out for radiologist report is requested, there will be additional charge

Clinic Name

Clinic Phone

Please enter a valid phone number.Format: 0000 0000.

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

example@example.com

Doctor First Name

Doctor Last Name

Patient Name

Species

Breed

Patient Sex

Neutered / Spayed

Weight

Patient Age or Date of Birth

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

Do you need VSI to provide contrast injection

Do you need VSI to send images for radiologist report (VetCT)?

If yes, please provide history for radiologist review.

Questions to be answered by radiologist.

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

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

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.

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.

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

Doctor Signature

CT Facility Rental Form

Clinic and Doctor Information

Patient Information

Release