Advanced Imaging Referral Form CLIENT INFORMATIONClient Name(Required) First Last Client Phone(Required)Client Email Client Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code REFERRING VETERINARIAN INFORMATIONDVM(Required)Hospital Name:(Required)Hospital Address:(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)FaxReferring Vet Email(Required) PET INFORMATIONPatient Name(Required)Species(Required)Breed(Required)Age(Required)Weight (Kg)(Required)Sex(Required) Male Male Neutered Female Female Spayed REFERRAL INFORMATIONModality Requested(Required) CT MRI Area to be Imaged(Required) Brain Nasal/Orbit Neck/Thyroid C1-T2 T3-L3 L4-S2 Brachial Plexus Shoulder Stifle Thorax Abdomen Pelvis Other (please specify in history section) Left or Right?(Required) Left Right Chief Complaint/Tentative Diagnosis(Required)Pertinent Medical History/Physical Exam Findings/Duration of Current Problem:(Required)Current Medication(s)(Required)Please include any known sensitivity to anesthesia or any known allergies. Special Requests/CommentsLaboratory Data Available?(Required) Yes No Please upload files of client records, bloodwork, etcMax. file size: 512 MB.Please be sure to include pertinent history and exam notes with all diagnostics. You may email [email protected] files that will not fit here.Radiographs Taken?(Required) Yes No If YES, please email digital Rads to [email protected] or send film/digital Rads with the client.Due to length of time under anesthesia, MRI scans are usually limited to no more than two sites per anesthetic event. If more than two sites are being requested, please email [email protected] or call (405) 594-4999 to discuss the request with the imaging team. In an effort to maximize diagnostic utility, the veterinary specialists may elect to alter the requested imaging modality and/or area to be imaged based on the history and physical exam findings on the day of presentation.
