PLEASE ENSURE ALL BOXES (THAT ARE COMPULSORY*)ARE FILLED OUT TO SUBMIT A PATIENT AND YOU HAVE HAD CONFIRMATION OF YOUR SUBMISSION. If you have any issues then please send history to info@northwestreferrals.co.uk

 

    Referring Practice details





    PATIENT DETAILS






    Area:

    HeadC1-T2T1-L1L1-SacrumOther




    Please check box below:

    Full ReferralOut-patient Scan

    Please bill:

    OwnerThe Vets

    Attached history:





     

    All reports are delivered to the email address above within 5 days (working) of the scan if you wish an urgent report then it can be done within 24 hours for an extra £90, please ask if wish need any specific details regarding your referral.

    PLEASE ENSURE YOUR CLIENT HAS SIGNED YOUR GENERAL ANASTHETIC CONSENT FORM (if we are picking the patient up in our dedicated ambulance).

    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 Northwest Referrals will act in the best interest of the patient.

    PLEASE ENSURE ALL BOXES (THAT ARE COMPULSORY*)ARE FILLED OUT TO SUBMIT A PATIENT AND YOU HAVE HAD CONFIRMATION OF YOUR SUBMISSION. If you have any issues then please send history to info@northwestreferrals.co.uk

     

      Referring Practice details





      PATIENT DETAILS






      Area:

      HeadThoraxAbdomenLimbsOther




      Please check box below:

      Full ReferralOut-patient Scan

      Please bill:

      OwnerThe Vets

      Attached history:





       

      All reports are delivered to the email address above within 48hours (working) of the scan if you wish an urgent report then it can be done within 4 hours for an extra £90, please ask if wish need any specific details regarding your referral.

      PLEASE ENSURE YOUR CLIENT HAS SIGNED YOUR GENERAL ANASTHETIC CONSENT FORM.

      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 Northwest MRI & CT will act in the best interest of the patient.

      PLEASE ENSURE ALL BOXES (THAT ARE COMPULSORY*)ARE FILLED OUT TO SUBMIT A PATIENT AND YOU HAVE HAD CONFIRMATION OF YOUR SUBMISSION. If you have any issues then please send history to info@northwestreferrals.co.uk

       

        Referring Practice details





        PATIENT DETAILS






        Area:

        OrthopaedicSoft tissueNeurosurgeryOther




        Please bill:

        OwnerThe Vets

        Attached history:





         

        All reports are delivered to the email address above within 48hours (working) of the scan if you wish an urgent report then it can be done within 4 hours for an extra £90, please ask if wish need any specific details regarding your referral.

        PLEASE ENSURE YOUR CLIENT HAS SIGNED YOUR GENERAL ANASTHETIC CONSENT FORM.

        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 Northwest MRI & CT will act in the best interest of the patient.

        PLEASE ENSURE ALL BOXES (THAT ARE COMPULSORY*)ARE FILLED OUT TO SUBMIT A PATIENT AND YOU HAVE HAD CONFIRMATION OF YOUR SUBMISSION. If you have any issues then please send history to info@northwestreferrals.co.uk

         

          Referring Practice details





          PATIENT DETAILS






          Area:

          One elbowTwo elbowsOne ShoulderTwo shouldersOne StifleTwo StiflesOther




          Please check box below:

          Full ReferralOut-patient Scan

          Please bill:

          OwnerThe Vets

          Attached history:





           

          All reports are delivered to the email address above within 48hours (working) of the scan if you wish an urgent report then it can be done within 4 hours for an extra £90, please ask if wish need any specific details regarding your referral.

          PLEASE ENSURE YOUR CLIENT HAS SIGNED YOUR GENERAL ANASTHETIC CONSENT FORM.

          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 Northwest MRI & CT will act in the best interest of the patient.

          PLEASE ENSURE ALL BOXES (THAT ARE COMPULSORY*)ARE FILLED OUT TO SUBMIT A PATIENT AND YOU HAVE HAD CONFIRMATION OF YOUR SUBMISSION. If you have any issues then please send history to info@northwestreferrals.co.uk

           

            Referring Practice details





            PATIENT DETAILS






            Area:

            AbdomenEchocardiographyTendonsChestThyroid and parathyroidSalivaryglandsLymphnodesMassesUltrasound guided FNAOther




            Please check box below:

            Full ReferralOut-patient Scan

            Please bill:

            OwnerThe Vets

            Attached history:





             

            All reports are delivered to the email address above within 48hours (working) of the scan if you wish an urgent report then it can be done within 4 hours for an extra £90, please ask if wish need any specific details regarding your referral.

            PLEASE ENSURE YOUR CLIENT HAS SIGNED YOUR GENERAL ANASTHETIC CONSENT FORM.

            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 Northwest MRI & CT will act in the best interest of the patient.