External Imaging Referral - MRI/ CT
Is this referral for a MRI or CT?
MRI
CT
Referring Vet Details
Clinic Name
*
Referring Vet Name
*
Email (imaging study will be sent here):
*
example@example.com
Client Details
Title
*
Please Select
Mr
Mrs
Miss
Ms
Dr
Client Name
*
First Name
Last Name
Clients phone Number
*
Client Email
*
example@example.com
Pet Details
Name
*
Weight (kg)
*
Microchip Number
*
Species
*
Please Select
Canine
Feline
Other
Breed
*
Sex
*
Please Select
Male
Female
Age
*
Date of Birth
-
Month
-
Day
Year
Date
Colour
*
Medical History
*
Yes
No
Has the patient has a blood test within the past 14 days?
Is the patient pregnant?
Does the patient have any preexisting conditions or allergy?
Is the patient on any medication?
Is the patient currently hospitalised?
If you answered yes to any of the above, please list the details/ medications.
Please list a brief clinical summary/ working diagnosis.
*
What are the clinical signs/ symptoms?
*
Please select if the patient has had any of the following.
Heart surgery
Metal in the eye or skin
Brain surgery
Surgical implants
Ear surgery
Pacemaker or defibrillatory
Had surgery in the past 8 weeks
Metal plates, rods, pins, or screws
Any form of implant
Shrapnel or bullet wounds
Eaten unusual objects
Intravascular stent or coils
If you answered yes to any of the above, please elaborate.
CT
Head
Spine
Neck
Thorax
Abdomen
Front limbs
Hind limbs
MRI
SPINE
C1 - C7
C6 - T2
T3 - L3
L4 - S3
Brachial Plexus
HEAD
Brain
Optic nerve
Ears
Orbit
MUSCULOSKELETAL
Right Forelimb
Left Forelimb
Right stifle
Left stifle
Right elbow
Left elbow
Additional
FNA - Fine needle aspiration
Ambulance transfer (at cost to the owner)
Pre GA blood work (if this has not been completed within 14 days of the imaging - at cost to the owner)
Keep IV catheter in place (only applicable if the patient is returning to the referring vet)
Documents and Consent
Additional comments:
Please upload blood results, previous imaging, and any other relevant documentation.
*
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