Imaging Referral

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

This form is for Veterinary Practice use only. Use this form to refer a patient for imaging only. Please note this service does not include a consultation with one of our vets. An imaging report will be forwarded within 5-7 days. If you require a quicker turn around time, please contact the hospital for further details.

Imaging Type Requested(Required)

Practice Name(Required)

Practice Name Practice Address Town/City Region Post Code

Practice Telephone Number(Required)

Referring Surgeon Name(Required)

First Last

Practice or Vet 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

Email Address

Insured(Required)

Yes

Not Sure

Patient Name(Required)

Patient Age(Required)

Breed(Required)

Sex(Required)

Clinical Details

Attach History to Form Submission. Please use PDF format.

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

Would you like us to use contrast?

Yes

Please specify what area/s you would like us to scan

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 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. You can also alternatively send them via email to info@yirvet.co.uk. If for some reason you cannot do this, please instead check the box indicating that you need YIR 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)

If Yes Please Provide Details

How to find us Contact us