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Advanced Outpatient Diagnostic Imaging Center
Virginia-Maryland Regional College of Veterinary Medicine
Duck Pond Drive
Blacksburg, VA 24061
Phone (540) 231 - 4621
Fax
(540) 231- 9238
WebPage: http://www.vetmed.vt.edu/vth/outpatient_imaging.asp
MR Request Form
Date of Request Submitted
Referring Veterinarian
Client
Hospital Name:
Owner's Name:
Name of Referring Veterinarian:
Address, Street
Address, Street
City
State
Zip Code
City
State
Phone # (area code)
E-mail Address
Zip Code
Phone # (area code) 2nd #
Phone # (area code)
Patient
Fax# (area code)
Patient's Name:
Please indicate what imaging studies have been performed
in the last year.
Radiographs
CT
Contrast Procedure
Ulltrasound
MR
Other
Please provide any imaging study performed
within the last year.
Indicate below how these studies will be provided.
Films will come with the client
Digital Images will come with the client
Images will be sent by ground mail
Images will be sent by e-mail
FOR OFFICAL USE ONLY
Imaging study approved for next available appointment
Approved by
Species
Date of Birth
Sex
Dog
Cat
Breed
Other
Color
Male
Female
Male-Castrated
Female-Spayed
Weight (lbs)
Date of last Rabies Vaccine
Anatomic Region to be imaged
(Procedures are charged per anatomic site)
Brain
Lumbar Spine T13-L4
Cervical Spine C1-C4
Lumbar Spine L4-S1
Cervical Spine C4-T5
LS Spine L7-S3
Thoracic Spine T5-T11
Extremity Shoulder
TL Spine T10-L2
Extremity Stifle
Primary Complaint:
Pertinent History:
Pre-existing Medical Conditions:
Current Medications:
Has this animal had complications related to anesthesia or a history of drug or contrast agent reactions? If so describe below:
Presumptive or Differential Diagnosis:
Specific question that you would like answered by imaging study:
Category
Description
Examples
1
Healthy patient
No Organic Disease
2
Mild or moderate systemic
disease without functional
impairment
Cardiac Disease, compensated (no medications)
Geriatric
Obesity
Orthopedic Disease
Pediatric
Organic disease with
definite functional
impairment
Anemia, mild
Anorexia
Cardiac Disease, compensated (with medications)
Dehydration, mild
Fever, mild
Neurologic symptoms (Seizures, Vestibular syndrome, Ataxia, Paresis)
4
Severe Disease that is lifethreatening
Anemia, Severe
Cardiac Disease, decompensated
Pulmonary Disease
Renal Failure
Sepsis
Shock
5
Moribund patient, not
expected to survive
Major Trauma
Multi-organ failure
Profound Shock
Severe Head injury
3
Select Anesthetic Category Based on Criteria Above
Category 1
Category 2
Category 3
Category 4
Category 5
NOTE: Only Patients in categories 1-3 are eligible for outpatient imaging. Patients in
categories 4 and 5 require a greater level of care and will have to be scheduled as a
referral through one of our speciality services such as internal medicine.
Testing Required for Patients < 5 years of age
Testing Required for Patients > 5 years of age
Category
Minimal Database Required
Test
time frame
Category
Minimal Database Required
Test
time frame
1
PCV, TP or Albumin, BUN,
Glucose
within 30 days
1
PCV, TP or Albumin, BUN,
Glucose, ECG, Urine Specific
Gravity
within 30 days
2
PCV, TP or Albumin, BUN,
Glucose
within 30 days
2
PCV, TP or Albumin, BUN,
Glucose, ECG, Urine Specific
Gravity
within 30 days
3
PCV, Albumin, White Cell Count,
ALP, ALT, T Bilirubin, BUN,
Creatinine, Glucose, Electrolytes within 7 days
(Na, K, Cl, Mg, Ca), HCO3, ECG,
Urine Specific Gravity
Medical Record
A copy of the medical record will come with the client
3
PCV, Albumin, White Cell Count,
ALP, ALT, T Bilirubin, BUN,
Creatinine, Glucose, Electrolytes within 7 days
(Na, K, Cl, Mg, Ca), HCO3, ECG,
Urine Specific Gravity
Blood Work
(must be received the day before the scheduled appointment)
A copy of the blood work will be sent by mail
A copy of the blood work will be sent by fax