CT Imaging Request
Practice name
Phone
-
Area Code
Phone Number
Referring Vet
Email address
example@example.com
Owner Details
Owner name
Owner surname
Phone
Format: 0000 000 000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email address
example@example.com
Patient Details
Patients name
Sex
Male
Female
Age
Species
Breed
Summary of history to inform radiologist
Questions to be answered
CT Imaging Request - Please select relevant boxes
Rows
Head
Neck
C1-T2
Spine
T3-Sacrum
Pelvis
Tail
Stifles
Vascular Contrast Study eg PSS
Elbow
Carpus
Foot
Tarsus
Foot
Thorax
Shoulder
Abdomen
Imaging Safety Questionnaire
Does the patient have any of the following? If so, please provide details
Heart disease/ Pacemaker
Y
N
Renal disease
Y
N
Known adverse reactions to medications
Y
N
Surgery within the previous two months
Y
N
Pregnancy
Y
N
Endocrine disease, bleeding disorder, neoplasia
Y
N
Epilepsy
Y
N
Priority - tick relevant box
Standard Non Urgent Within 4 business days
Enhanced (1-2 days)
Priority (up to 24 hours)
Urgent (within 4 hours)
NOTE: By submitting this form you confirm that you are a registered veterinary surgeon who has obtained consent from the patient's owner to act on behalf of the animal described above; that the owner has given permission for the administration of an anaesthetic to the above animal at the imaging location together with any other procedures that may prove necessary; and that the owner understands that in the unlikely event of an emergency or where additional pain relief or sedation may be required, the Macksville Veterinary Clinic will act in the best interests of the patient; that the owner has agreed that they have understood that medicines may be used which are not licensed for use in dogs and cats; and that in the event that you cannot be contacted on the above number, you understand that the Macksville Veterinary Clinic will act in the best interests of the patient.
MACKSVILLE VET CLINIC - 19 River Street, Macksville, NSW 2447, Ph: 6568 1252, email ctsurgery@midcoastvets.com.au
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