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.

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Referring vet - 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.

Type of Image/Modality(Required)

Region of Scan(Required)

Referring Practice

Referring Veterinarian

Vet - Email Address(Required)

Email Address Confirm Email Address

Client Contact Details(Required)

First name Last Name

Client - Phone Number(Required)

Client - Email(Required)

About Your Patient + Reason for Imaging(Required)

Brief summary of patient details - name - species, breed, age, weight etc - reason for scanning - relevant patient history

Any known implants?(Required)

Yes

If yes, please specify in patient history above.

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

Drop files here or

Max. file size: 128 MB.

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106 Parraweena Road,
Miranda NSW 2228

(02) 8376 8767

info@vsos.com.au

Outpatient Imaging Request Form