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 run a full blood profile:

    YesNo

    Is the pet insured with the RSA?:

    YesNoDon't know

    Please bill:

    OwnerThe Vets

    Attached history:

    Please prove you are human by selecting the house.

     

    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 £250, please ask if wish need any specific details regarding your referral.

    If you submit an Out-Patient scan and we feel this must be a full referral we will contact your practice to discuss this further and obtain your permission to change it to a full referral.

    Information for Ambulance pick up only*

    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, Northwest Referrals 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 run a full blood profile:

      YesNo

      Is the pet insured with the RSA?:

      YesNoDon't know

      Please bill:

      OwnerThe Vets

      Attached history:

      Please prove you are human by selecting the heart.

       

      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 £250, please ask if wish need any specific details regarding your referral.

      If you submit an Out-Patient scan and we feel this must be a full referral we will contact your practice to discuss this further and obtain your permission to change it to a full referral.

      Information for Ambulance pick up only*

      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, Northwest Referrals 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:

        OrthopaedicSoft tissueNeurosurgeryOther

        Is the pet insured with the RSA?:

        YesNoDon't know

        Please bill:

        OwnerThe Vets

        Attached history:

        Please prove you are human by selecting the tree.

         

        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 £250, please ask if wish need any specific details regarding your referral.

        If you submit an Out-Patient scan and we feel this must be a full referral we will contact your practice to discuss this further and obtain your permission to change it to a full referral.

        Information for Ambulance pick up only*

        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, Northwest Referrals 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:

          One elbowTwo elbowsOne ShoulderTwo shouldersOne StifleTwo StiflesOther

          Please check box below:

          Full ReferralOut-patient Scan

          Is the pet insured with the RSA?:

          YesNoDon't know

          Please bill:

          OwnerThe Vets

          Attached history:

          Please prove you are human by selecting the tree.

           

          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 £250, please ask if wish need any specific details regarding your referral.

          If you submit an Out-Patient scan and we feel this must be a full referral we will contact your practice to discuss this further and obtain your permission to change it to a full referral.

          Information for Ambulance pick up only*

          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, Northwest Referrals 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:

            AbdomenEchocardiographyTendonsChestThyroid and parathyroidSalivaryglandsLymphnodesMassesUltrasound guided FNAOther

            Please check box below:

            Full ReferralOut-patient Scan

            Is the pet insured with the RSA?:

            YesNoDon't know

            Please bill:

            OwnerThe Vets

            Attached history:

            Please prove you are human by selecting the truck.

             

            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 £250, please ask if wish need any specific details regarding your referral.

            If you submit an Out-Patient scan and we feel this must be a full referral we will contact your practice to discuss this further and obtain your permission to change it to a full referral.

            Information for Ambulance pick up only*

            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, Northwest Referrals 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.