Imaging Request Form

✖

Pet Health for Life Plan

Spread the cost of your pet’s essential healthcare

Sign up online

Type of scan *

CT MRI

Practice Details

Practice Name *

Tel *

Address *

Referring Vet *

Vet E-mail *

Animal Details

Owners name *

Tel *

Address *

Animal's Name

Age

Sex

Breed

Weight (Kg)

In order for us to provide the optimum examination please give a brief clinical history including presenting signs, provisional diagnosis and ongoing medication. (Please attach a copy of all relevant history). *

Anaesthetic Risk *

I confirm that the patient is compliant with the statements below. If not, please detail above. *

Has no known heart or renal problems
Does not have any metal fragments in eyes or any other part of the body
Has not had any operations involving the insertion of metal implants, plates or clips
Does not have any type of electronic, mechanical or magnetic implant (excluding microchip)
Has not had any surgery in the previous two months
Is not pregnant
Has no known adverse reaction to iodinated x-ray contrast agent

Areas to be Scanned

Spine

Cervical Thoracic Lumbar Sacrum

General

Chest Angio Abdo Brachial Plexus

Other

Privacy

Pets'n'Vets is part of Linnaeus Veterinary Limited. We will not share this information with other companies for their marketing purposes. For more details on how we use your information please see our privacy policy.

The personal data submitted via this form will be retained only for the purpose of responding to your question or concern, and will not be used for marketing purposes.

You must be 16 years old or older to submit a form.

I agree to the Privacy Statement *

Captcha *

You must enable "Performance Cookies".

Cookie Settings