Outpatient Imaging Request Form

This form is for you to request a CT scan, MRI study, abdominal ultrasound or echocardiogram as an outpatient service. Please note that you will remain the case-owner and the patient will not see a specialist. Therefore, please ensure you select the correct modality. If you are in doubt, please call or email our team to discuss the case: info@vsos.com.au or (02) 8376 8767.

Please fill out the below information about your client/patient and upload all relevant history and blood work so that we can process your request as quickly as possible.

Thank you.

Type of Image/Modality:: Please Select
Referring Practice:
Referring Veterinarian:
Vet - Email Address:
Confirm Email Address:
Client Contact Details:: First Name:
Last Name:
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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