Veterinarian - Non-Neurological CT/MR Imaging Referral

Non-Neurological CT/MR Imaging Referral Form

Please review the VNC's CT/MR Imaging Referral Process prior to submitting this form. This form and special pricing is for non-neurological cases only. Please contact us if you have questions.

Owner Information

Please Select:

First Name & Middle Initial:

Last Name:

Address:

City:

State:

Zip Code:

Phone (home):

Phone (cell):

Fax:

Email:

Patient Information

Pet's Name:

Breed:

Species:

Sex:

Age

Referring Veterinarian Information:

Name:

Hospital:

Telephone:

Fax:

Address:

Email:

City:

State:

Zip Code:

Medical History

Tentative Diagnosis:

History & Clinical Findings:

List any known metal in patient (e.g. IM pins, plates, etc.)

Imaging Study Requested:

Comments

Drug Senstivities/Allergies?

Previous Imaging Studies?

Date

Location

Previous Surgery?

Date

Location

Please fax or upload (below) a copy of current CBC, Chemistry Profile, UA performed within the last 10 days:

Fax

Upload

Unavailable

Maximum File Size: 1000KB
File Types: .jpg .doc .pdf .zip

Unless otherwise requested, imaging interpretation will be performed by either:

Jaime Sage, D.V.M., M.S., Diplomate ACVR
Veterinary Imaging Consultant (Specializing in MRI)
Austin, Texas

Permission to send imaging to Dr. Sage? In either case, a link to the imaging study will be emailed to the referring veterinarian.

Would you like to receive a copy of the client's estimate for your records?

Additional Comments

In order to ensure you have a backup of your submission, please print and/or email a copy of this form.

To print a copy of this form:

Prior to submission, click the print function from your browser.

To receive a confirmation copy of this form via email:

Enter your email address in the Email Address box
If you do not receive the confirmation copy shortly after submission, please contact us.

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