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
*
Click to select
Hip Screening
Elbow Screening
Hip & Elbow Screening
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Part Two: Owner Details
Please provide your contact details so we may register the appointment and contact you with appointment details.
Owner's Name
*
Ms.
Mrs.
Mr.
Dr
Prof.
Prefix
First Name
Last 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 Name
Last Name
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Part Three: Patient Details
Please provide patient details
Patient's First Name
*
Breed
i.e. Labrador etc
Colour
i.e. Yellow etc.
Age
*
-
Day
-
Month
Year
Date
Has this patient been referred to UCDVH previously?
Yes
No
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
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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.
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Microchip Registration Form
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Please verify that you are human
*
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