Imaging Request Form

Imaging Request Form
For patients undergoing anesthesia:

Please provide CBC & Chem screen of less than 30 days.

Patients should be receiving IV fluids (at maintenance rate) for 2–3 hours prior to procedure, unless contraindicated.

We recommend administering an antacid (i.e., Famotidine) parenterally at the time of catheter placement to minimize the chances of anesthesia related esophagitis.

For patients undergoing a procedure without anesthesia (i.e., swallow study or tracheal fluoroscopy):

No preparation is needed.

For swallow studies, patients should be fasted 18–24 hours unless medically contraindicated. Call us if patient is hyperactive and may need a mild sedative.
VETERINARIAN INFO
Veterinarian's Name and Last Name *

First Name Last Name
Hospital / Clinic Name *
E-mail (for receiving reports) *
Phone Number *

Area Code Phone Number
PATIENT INFO
Owner's Name and Last Name *

First Name Last Name
Patient's Name *
Species / Breed *
Sex *
Weight *
Age (Approximate if not known) *
TYPE OF IMAGING REQUESTED

You may check more than one region if necessary. Note that each area incurs additional fee.
CT SCANS

Skull CT Thoracic CT (Primary region of interest or met-check) Abdominal CT Pelvic CT Appendicular Skeleton CT Cervical Spine CT Thoracic Spine CT Lumbar Spine CT Lumbosacral Spine CT
Specify joint or limb for Appendicular Skeleton CT (includes scan of contralateral joint for comparison, when indicated.)
FLUOROSCOPY

Fluoroscopy Study (i.e. swallow study, collapsing trachea, urethral study, etc.)
Specify Fluoroscopy Area

Swallow study (no anesthesia consent needed) Collapsing trachea (no anesthesia consent needed) Urethral study
REASON FOR IMAGING
Presenting complaint or concern *
PATIENT HISTORY

This helps us when designing anesthetic procedures and interpreting the images.
MEDICAL RECORDS / BLOODWORK *
Pull down to choose one:
Please email any medical records files to requests@mobilepetimaging.com
Please Fax records to 305.397.2734
Upload Medical Records 1
Upload Medical Records 2
Upload Medical Records 3
Upload Medical Records 4
PREVIOUS IMAGING (Include any X-Rays, CT, MRI, Flouroscopy) *
Pull down to choose one:
Upload Files 1
Upload Files 2
Upload Files 3
Upload Files 4
Please email any previous imaging files to requests@mobilepetimaging.com
FINDINGS
List any abnormal findings on physical exam, including cardiovascular, respiratory, neurologic, genitourinary, musculoskeletal, alimentary, etc. *
CURRENT MEDICATIONS
Is the pet receiving any medications? *

Pet is NOT receiving any medications Pet IS receiving medications (including any on regular basis)
Please list any medications, including any being taken on a regular basis
ALLERGIES AND/OR DRUG REACTIONS
In particular to iodine or anesthetic drugs *
ANESTHESIA
Anesthesia Consent Form signed by pet owner *
Pull down to choose one
Please make sure to get consent form signed by pet owner on date of procedure. It can be downloaded as a PDF or filled out electronically at: itstimetoseemore.com
Should be Empty:

Imaging Request Form

VETERINARIAN INFO

PATIENT INFO

TYPE OF IMAGING REQUESTED

REASON FOR IMAGING

PATIENT HISTORY

CURRENT MEDICATIONS

ALLERGIES AND/OR DRUG REACTIONS

ANESTHESIA