CT/MRI Booking Form

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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

Head

Brain

Nasal

Bullae

ST Head

ST Neck

Spine

Cervical

Thoracic

Lumbar

Sacrum

Orthopaedic

Stifle

Elbows

Tarsi

Limb

Shoulders

Hips/Pelvis

Carpi/Paws

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 *

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