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MRI Referral Form

MRI Referral Form

Please fill out the form below or Download the form and send it to us via email. If you experience any problems making an online referral, please call us on +971 (2) 412-6555 or email imagiology@drvet.ae

    Clinic Information



    How would you like to be informed of the results?

    FaxE-mailOther

    Client Information:


    Patient Information:

    DogCat

    kgslbs

    Appoinment Information:

    Appointment is On


    The Patient will come with
    OwnerClinic EmployeeOther

    Documents (Max 2MB):

    X-rays (Max 2MB):

    Region that shall be scanned:
    Spinal Cord

    C1-5

    C6-Th2

    Th3-L3

    L4-S3

    Head -CNS and Ears

    Splanchnocranium CNS/Joint

    C1-5

    Kindly provide brief description on general medical history/ diagnosis/ chronic disease/ anesthesia reaction/ know allergic reaction/ sensitivity.

    Medications (Please list all current drugs and dosages: Indicate special diet needs)

    Recent CBC & Biochemistry Result

    Kindly note results should be within two days prior to scheduled scan date. (This is mandatory for anesthesia).

    Referral veterinarian will perform and upload the result on your user accountPlease perform at Dr Vet Animal Hospital

    Spinal Tap Requested?

    Collection of cerebrospinal fluid (CSF) from the spinal canal can be performed under same sedation and after the scan at an extra cost.

    YesNo

    Does the patient have pacemaker, microchip, hemoclips or other implants?

    YesNo

    Has this patient has a previous CT/MRI done?

    YesNoNot Sure

    Microchip Removal Requested (at an additional cost) Before the scan?

    If the microchip is located close to the area of interest that needs to be imaged, it can potentially cause artifact on the MRI images. In such cases, it might be advisage to consider removing the microchip to ensure the quality of the images.

    YesNo

    Please select how soon you need the diagnostic report. Our pricing varies based on the urgency level you choose:

    Standard Report: Receive your report within 2-4 working days.

    Urgent Report: Your report will be ready within 6 hours after the MRI is completed. (During weekends, can take up to 24 hrs)

    I agree to the Terms and Conditions and Privacy Policy and to use the information provided above to process our request efficiently.

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