Image Referral Form

For referring veterinary surgeons

Practice Details

Owner Details

Please leave non-mandatory fields if they are in the patient history.

Do you wish to discuss this case before we contact the owner?:

Patient Details

Please leave non-mandatory fields if they are in the patient history.

Neutered:

Service Required

Area(s) to be imaged*:

Please note:

  • As metallic objects and microchips can cause artifacts in both MRI and CT scans it is helpful to know in advance if any may be present in the patient.
  • A pacemaker if present, can be irretrievably damaged during MRI scans therefore if a patient has one in place, another form of scan must be selected.
Does the patient have any of the following?:

Further Information

Please confirm how you will send further patient information ie referral letter, full patient history, lab results/xrays.:

Insurance Details

Security Question:

 

Terms & Conditions of imaging only service

  • CT and MRI cases can be sent to us for imaging only without being fully referred to us.
  • Upon imaging the case, you have the option to interpret the images yourself/ via a third party, or we will provide a full report.
  • The client will have an admission and discharge appointment with a VN and will not see our clinicians for consultation, hence a referral consult fee will not apply.
  • Contrast media used in advanced imaging are used with caution in patients with impaired renal or liver function, therefore all patients sent for imaging must have had a preoperative blood screening test within the last 2 weeks, if this has not been done, or no results have been provided by the referring vet, a Pre-Ga blood test will be performed on the day of imaging at an additional cost to the owner.
  • Clients are required to pay in full for imaging on the day of the procedure, no direct claims will be accepted therefore please make sure clients are aware of the costs before making the appointment.
  • We accept most debit and credit cards and cash as forms of payment.
  • We will not discuss imaging results with the owners, give any treatments or treatment recommendations.* (*except in emergency situations where the patient’s welfare is at risk, in such cases we will always try to contact you first to keep you informed.