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Advanced Imaging Request Form

Make an imaging referral below

For stable patients, we offer an out-patient imaging only referral service for CT (Monday-Friday) and MRI (Monday-Wednesday), excluding bank holidays. This service does not include referral consultation or interpretation of findings and imaging reports are sent directly to the referring practice.  We are not able to carry out any additional diagnostic tests or accept unstable patients.  If you have any questions about the most suitable imaging modality then please email referrals@earlswoodveterinary.com, submit an advice request or speak to our referrals co-ordinator on 028 90471361.

Reporting times:

  • standard (4 to 7 business days)
  • enhanced (2 business days)
  • priority (24 hours)

Practice Details

Client Details

Patient Details

Neutered
Is an urgent report required?*
Please note that additional fees are charged for non-standard reporting
Have pre-anaesthetic bloods been performed prior to admission?

Imaging Request

Imaging details*
Body Areas
Additional charges will apply to multiple areas

Imaging Safety Questionnaire

Heart disease/pacemaker*
Renal disease*
Known adverse reactions to medications*
Surgery within the previous two months*
Metal fragments / implants any location*
Pregnancy*
Endocrine disease, bleeding disorder, neoplasia*
Epilepsy*

Financial Details

Do you require an estimate prior to referral?
Insured?

Please note that for clients that are non-insured we require a deposit of 50% of the upper end of the estimate at the time of admission. A full estimate will be provided at the time of consultation. For insured clients we require a deposit of £170 plus a £30 direct claim administration fee where applicable. All insured clients are required to bring a copy of their insurance policy documentation along with a signed claim form.

 

 

Security Question
 
Note: By submitting this form you confirm that you are a qualified veterinary surgeon who has obtained consent from the patient’s owner to act on behalf of the animal described above; that the owner has given permission for the administration of an anaesthetic/sedative to the above animal at the imaging location together with any other procedures that may prove necessary; and that the owner understands that in the unlikely event of an emergency or where additional pain relief or sedation may be required, the imaging branch will act in the best interests of the patient.; that the owner has agreed that they have understood that medicines may be used which are not licensed for use in dogs and cats; and that in the event that you cannot be contacted on the above number, you understand that the imaging branch will act in the best interests of the patient.