Non-Neurological_CT/MR_Imaging_Referral_FormPlease 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 InformationPlease Select- Select -Mr.Mrs.Ms.Dr.First NameMiddle InitialLast NameAddressAddress Line 1Address Line 2CityStateZip CodeHome PhoneCell PhoneFaxEmailPatient InformationPets NameBreedSpeciesSexAgeReferring Veterinarian InformationNameHospitalTelephoneFaxAddressAddressCityStateZip CodeEmailMedical HistoryTentative DiagnosisHistory & Clinical FindingsList any known metal in patient (e.g. IM pins, plates, etc.)Imaging Study Requested- Select -CTMRIRequested Area of Study Abdomen Thorax Adrenals/Pituitary Bone (specify) Joint (specify) Nose/Sinuses OtherCommentsKnown Anesthetic Risks Cardiac Pulmonary CNS Metabolic OtherCommentsDrug Senstivities/Allergies?Previous Imaging Studies?- Select -YesNoDateLocationPrevious Surgery?- Select -YesNoDateLocationPlease fax or upload (below) a copy of current CBC, Chemistry Profile, UA performed within the last 10 days Fax Upload UnavailableMaximum File Size: 1000KBFile Types: .jpg .doc .pdf .zipFile UploadChoose File Jaime Sage, D.V.M., M.S., Diplomate ACVRVeterinary Imaging Consultant (Specializing in MRI)Austin, TexasPermission to send imaging to Dr. Sage? In either case, the VNC will send the study to the referring veterinarian- Select -Dr SageAdditional 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. Your EmailSubmit Form
