SMALL ANIMAL CT/MRI REQUEST REFERRAL FORM

When arriving for an MRI or CT, the patient drop off is 7:30 AM.

Imaging times may be subject to change due to emergencies or unforseen circumstances. Please perform all pre-anesthetic workup prior to sending the case so that your patient can be seen in a timely manner.

Patients with incomplete work-ups may have to be rescheduled. Pre-anesthetic workup includes:

1. Three view thoracic radiographs for animals older than 5 years of age, or any age animal with concern for cardiopulmonary disease, within a month of the procedure.

2. CBC and chemistry panel within a month of the procedure.
a. Please note: if there are health status changes between the time of bloodwork and the time of appointment, more current labwork may be indicated.

If there are any concerns or logistical difficulties with performing these pre-anesthetic tests, or should you have any questions, please feel free to contact us at (405) 744-7000 option 3 and ask for CT/MRI referral. (Receptionists will collect contact info and have someone contact you for scheduling or you can email directly to surgery_tech@okstate.edu .)

Thank you for your referral.

Sincerely, Oklahoma State University Veterinary Teaching Hospital Diagnostic

Imaging Service Phone: 405-744-7000 option 3
Email: surgery_tech@okstate.edu
Website: https://vethospital.okstate.edu/
RDVM Information
Date Date / MM / DD YYYY
Referring Doctor Referring Doctor First Last
Referring Hospital
Referring Phone Number Referring Phone Number - ### - ### ####
Results will be emailed within 72 hours. Please provide an email you would like results to be sent to.
Client Information
Client Name Client Name First Last
Contact Phone Number Contact Phone Number - ### - ### ####
Patient Information Patient Information First Last
Patient Type

Patient Type Dog Cat
Patient Breed
Sex

Sex Female Male
Is your Patient...

Is your Patient... Spayed Neutered
Age/Birthdate
Patients Weight (please indicate kg/lb)
Exam(s) Requested

MR- Region to Examine
CT- Region to Examine
Brief Summary of Patient History, Lab Results, Clinical Findings, Recent Treatments:
Detailed description of the case
Anesthetic Concerns? Yes or No (If yes, please explain)
Recent Radiographs (If yes, please email to surgery_tech@okstate.edu)

Recent Radiographs (If yes, please email to surgery_tech@okstate.edu) Yes No
Recent Bloodwork (If yes, please email)

Recent Bloodwork (If yes, please email) Yes No
Recent Urinalysis (If yes, please email)

Recent Urinalysis (If yes, please email) Yes No
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SMALL ANIMAL CT/MRI REQUEST REFERRAL FORM

SMALL ANIMAL CT/MRI REQUEST REFERRAL FORM

RDVM Information

Client Information