Outpatient Imaging Request Form

Type of Image/Modality:: Please Select
Region/s (if known):
Referring Practice:
Referring Veterinarian:
Vet - Email Address:
Client Contact Details:: First Name:
Last Name:
Client Email Address:
Client - Phone Number:
Patient Name:
About Your Patient + Reason for Imaging
Brief summary of patient details - name - species, breed, age, weight etc - reason for scanning - relevant patient history:
Any known implants?:: YesNo
If yes, please specify:
Upload Relevant Recent History & Blood Work: Please upload below all relevant history or conditions that we may need to know about prior to performing outpatient diagnostic imaging. Please also upload your patient's most recent bloods. Blood work is required for our imaging within 14 days of imaging.
File Upload - blood work and relevant history
Have the costs been discussed with your client?:: Yes I have explained the cost expectations of imaging to my client.
Consent and Acknowledgement of Bloods:: By clicking here, I acknowledge that I have read and agree to this disclaimer.
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-GA blood panel for this animal and have attached the documents to this submission. I am aware that if the bloodwork has not been completed within the past 14 days it will be completed at VSOS, on the days of the appointment, this will be at the cost to the owner. I am submitting this imaging referral on behalf of the owner.

Outpatient Imaging Request Form

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