UCDVH External Diagnostic Imaging Request Form

Diagnostic Imaging Screening Request Form

A member of our Vethub team is standing by to receive your request for an appointment with our Diagnostic Imaging Department. This request form is for Hip and Elbow Screening Service Only. Please complete the form which is divided into three sections: Imaging Details, Owner Details and Patient Details.
Part One: Imaging Required
Select what screening is required*
Do you require Eye Certification at this screening appointment?*

Part Two: Owner Details

Please provide your contact details so we may register the appointment and contact you with appointment details.
Owner's Name*

PrefixFirst NameLast Name
Address*

Address Line 1

Address Line 2

County

Eircode
Telephone Number
Mobile Number*
Email Address*
example@example.com
Additional Contact Number
Additional Contact Name

First NameLast Name

Part Three: Patient Details

Please provide patient details
Patient's First Name*
Breed
i.e. Labrador etc
Colour
i.e. Yellow etc.
Age*

DayMonthYear
Date
Has this patient been referred to UCDVH previously?

YesNo
Upload Documents

In order to accurately process your request and complete the required documents for screening certification, please upload a copy of the following forms:
Kennel Club Registration Number*
Number is required if KC registered for screen certification, if not KC registered enter "N/A"
Kennel Club Registration Form

The Kennel Club registration document must include details of the parentage, dogs lineage for submissin to the BVA. If this information is omitted at the time of screening it will effect the registration of the dogs progeny, as the Sire and Dam can not be included in screening documentation retrospectively. Document upload is Not required for Guide / Assistance Dog Screening.
Cancelof
Microchip Registration Form

Cancelof
Please verify that you are human*
Should be Empty:

Diagnostic Imaging Screening Request Form