IMAGING REFERRAL

You can refer a patient for imaging by CT or MRI without a clinical
consult using the form below.

Imaging Referral

This form is for Veterinary Practice use only. Use this form to refer a patient for imaging only.

Imaging Type Requested(Required)

Practice and Referring Surgeon Details(Required)

Practice Name Practice Address Town/City Region Post Code

Practice Telehphone Number(Required)

Referring Surgeon Name(Required)

First Last

Email Address(Required)

Client and Patient Details

Title(Required)

Surname(Required)

Owner Address(Required)

Address Line City Region Postal Code

Home Phone Number

Mobile Number

Insured(Required)

Yes

Not Sure

Patient Name(Required)

Patient Age(Required)

Breed(Required)

Sex(Required)

Clinical Details

Please indicate below whether your patient has ever shown signs similar to the referred problem in one of the check boxes below.

Attach History to Form Submission. Please use PDF format.

Accepted file types: pdf, Max. file size: 20 MB.

Short Story(Required)

Anaesthetic Risk (If medium or high please indicate the reason in the box above and discuss with owner)(Required)

Low

Medium

High

In many cases we will need to use intravenous contrast (CT and MRI) in order to improve the diagnostic accuracy of the scan. This requires that there is adequate renal and hepatic function to clear the contrast. As a result we request that you perform blood tests prior to referral for imaging and attach the lab results to this form. If for some reason you cannot do this, please instead check the box indicating that you need Torrington Orthopaedics to perform these lab tests on the day of the scan.

Is the Patient on Medication?(Required)

Has the Patient a History of Adverse Drug Reaction?(Required)

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IMAGING REFERRAL