Outpatient Imaging Referral

IMAGING INFORMATION

Would you like the vrec to review the case history and contact you with radiographic recommendations if different from this request?
What area(s) would you like to be included in the study?
Contrast is recommended for most soft-tissue studies and requires general anaesthesia.
What specific questions (if any) would you like the radiologist to answer?
Radio options for Turnaround Time
What is the required turnaround time for the report?
Would you like us to initiate any treatment indicated by the results of the imaging study if treatment is urgent or requested by the client?
Radio options for Unfit For Sedation Instruction
What would you like the vrec to do in the event that the patient is deemed unfit for sedation or general anaesthesia at the time of their appointment?

PRACTICE DETAILS

OWNERS DETAILS

PET DETAILS

Please attach your patient's history. Accepted formats are .png, .jpg, .gif, webp, .pdf. Attachments are limited to 6MB's in size.

INSURANCE & PRIORITY

Please attach supporting documents. Accepted formats are .png, .jpg, .gif, webp, .pdf. Attachments are limited to 6MB's in size.