External Imaging Referral

Is this referral for an MRI or CT?:

MRICT

Referring Vet Details

Clinic Name:

Referring Vet:

Email (imaging study will be sent here):

Client Details

Title:

Phone:

Email:

Patient Details

Name:

DOB:

Weight (kg):

Age:

Colour:

Sex:

MaleFemale

Species:

Breed:

Microchip #:

Has the patient had a blood test within the past 14 days?:

YesNo

Is the patient pregnant?:

YesNo

Does the patient have any preexisting conditions or allergy?:

YesNo

Is the patient on any medication?:

YesNo

Is this patient currently hospitalised?:

YesNo

If findings indicate a FNA or minor procedure, do you want to proceed at the Veterinarian’s best judgement?:

YesNo

If yes to any of the above, please elaborate:

MRI – Please select the required sites for study : SPINE:

C1 – C7C6 – T2T3 – L3L4 – S3

MRI – Please select the required sites for study : HEAD:

BrainOptic nerveEarsOrbit

Please specify if any other regions are required:

Additional – Please select if any of the following are required:

Fine needle aspirationCSF tapAmbulance transfer (at cost to the owner – patient only)Pre GA blood work (if has not been completed within 2 weeks – at cost to the owner)Keep IV catheter in place (only applicable if patient is returning to referring vet)

Additional comments:

I agree to Terms & Conditions

I hereby acknowledge and agree to the content of this form and the terms and conditions. I declare that I am a qualified Veterinarian and have completed a physical examination on this animal within the last 14 days. I have completed a pre-anaesthetic blood test for this animal and have attached the documents to this referral. I am submitting this imaging referral on behalf of the owner.

Signature:

Date:

Email Address

External Imaging Referral - MRI/CT

Services

.

For Pet Owners

For Vets & Nurses

Mobile Services

Contact Us

Acknowledgement of Country