Equine MRI Referral Form - Animal Imaging

Date of Submission*

Registered Name*

Barn Name

Breed*

Gender*

Age*

Color*

Owner's Name*

Owner's Phone*

Owner's Email Address*

Main Contact (if different than owner)

Main Contact Phone

Main Contact Email

Referring Veterinarian*

Veterinarian Contact Phone*

Referring Clinic*

Email Copy of Report To*

The lameness ideally will have been blocked to a specific region of interest. Another area will result in additional time and fees.

Affected limb(s) and region(s) to image:*

Additional exams/regions needed:*

Degree of Lameness and Diagnostic Anesthesia*

Right Front
Left Front
Right Hind
Left Hind

Please select affected limb(s) for Baseline Lameness and Block Response input

Lameness and Block Response (%)

Baseline Lameness (scale of 1 to 5; 5 = extreme):	PDN:	Abax:	Low-4:	Susp:	Other (specify):

Onset of lameness:*

Duration of lameness:*

Hoof Testers Result - Right Front*

Hoof Testers Result - Right Hind*

Hoof Testers Result - Left Front*

Hoof Testers Result - Left Hind*

History/Lameness Exam Findings*

Athletic modality/use:*

Previous Radiographs?*

Yes
No

Previous Radiographic Findings*

Please list any significant radiographic findings

Previous Ultrasound?*

Yes
No

Previous Ultrasound Findings*

Please list any significant ultrasound findings

Foreign Metal Object Present?*

Yes
No

Foreign Metal Object Location*

Please list location of any foreign metal objects

Previous Surgery?*

Yes
No

Previous Surgery*

Please list any previous surgeries for patient

Current Therapy*

Select MRI Type:*

3T MRI -- Each patient should have a physical exam, CBC, and/or chemistry panel to ensure safe general anesthesia (approximately 1.5 to 2 hours). If available, send lab results with this referral. Location: Irving, TX. Strongly recommended arrival by 2:00pm the day prior to appointment, but must arrive no later than 7:00am the day of MRI. Please call at 12:00pm for exact discharge time.
Standing MRI -- Standing MRI is available for feet, pasterns, fetlocks & front suspensory only. Patient will require prolonged light sedation. All shoes will need to be pulled. This can be done at Animal Imaging. Location: Irving, TX. Strongly recommended arrival by 2:00pm the day prior to appointment, but must arrive no later than 7:00am the day of MRI. Due to the uncertainty of imaging time, it is possible that the patient will need to stay overnight. We will call when the patient is ready to be discharged. Location: Irving, TX. Strongly recommended arrival by 2:00pm the day prior to appointment, but must arrive no later than 7:00am the day of MRI. Please call at 12:00pm for exact discharge time.

Please upload any relevant records, labs, and radiographs for this referral.

Drop files here or

Max. file size: 128 MB.

Veterinarian's Signature*

Veterinarian Certification*

I certify that I am a licensed veterinarian that has performed a physical examination on the aforementioned patient and am submitting this referral on their behalf.