MRI Request Form

MRI Request Form

* For Referring Veterinarians Only
Specifics of your request such as questions about positioning and scan time can be directed to the imaging veterinarian or the technologist on duty. We will do our best to accommodate your requests, but same-day scans may not be possible due to pre-existing case load.

We will reach out to the client to schedule once we have received the request and all necessary medical records (blood work and/or chest radiographs).

This form should be submitted at least 24 hours in advance of the date that you are requesting. All imaging requests require recent CBC/Chem blood work (within the last month). Incomplete packages (i.e. no blood work) will not be reviewed until all information is provided.

Medical Information
Anatomic Regions to Be Scanned (Select All That Apply)*

Head/BrainCervical SpineLeft Brachial PlexusRight Brachial PlexusLeft ShoulderRight ShoulderThoracolumbar SpineOther (Please specify in history)
Is a STAT Read required?*
What diseases/problems are you trying to rule out?*
This will aid the radiologist when reading the scan.
Pertinent Medical History *
Current Medications and/or Any Allergic Reaction to Medications*

Requesting Veterinarian Information
Name of Requesting Veterinarian*

First Name Last Name
Requesting Veterinarian Email*
example@example.com
Requesting Veterinarian Number *
Please enter a valid phone number.

Hospital Information
Hospital Name *
Specialty
If Applicable
Hospital Phone Number*
Please enter a valid phone number.
Hospital Email *
Report will be emailed within 1 business day.
Hospital Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Client Information
Client Name *

First Name Last Name
Client Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Client Phone Number*
Please enter a valid phone number.
Secondary Client Phone Number
Please enter a valid phone number.
Client Email*
example@example.com

Patient Information
Patient Name*
Species*
Breed*
Age*
Sex*
Weight (kg):*
Is the patient fearful or aggressive? Should our staff use caution?*

Upload Documents
Upload CBC/ CHEM Results or Additional Documents

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Requests will not be reviewed or scheduled until all necessary information has been received.
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