MRI REFERRAL FORM

Referring Doctor's Name

First Name

Last Name

Referring Hospital

Hospital Email

Please indicate the area of interest

Pet Owner Name

First Name

Last Name

Pet Owner's Email

Pet Owner's Phone Number

(###)

###

####

Species

Patient Name

Patient Breed

Patient sex

Pet's weight in kg

Patient history

Please list any current medications

Do you have any specific questions, concerns or goals for that we can pass on to the radiologist?

If your patient has renal disease, there is increased risk of renal complications with the use of contrast.

My patient does not have renal disease

My patient does have renal disease, and I do want contrast given.

My patient does have renal disease, and I do not want contrast given.

Does your patient have any cardiac or respiratory concerns that increase the risk of anesthesia?

Yes

If so, please describe

Will you be providing your patient with oral sedation for this appointment?

Yes

If so, please list medications and instructions.

Please note that this form is for a veterinarian or veterinary hospital to request an MRI for one of their patients. For our outpatient imaging services, referral to our hospital by your veterinarian is required.

All patients undergoing MRI will be placed under general anesthesia. We request that pre-anesthetic bloodwork be performed no more than 2 weeks prior to the appointment.

MRI REFERRAL FORM

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