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MRI Referral Form

Dr Vet Animal Hospital > MRI Referral Form

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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

Date

Referring Hospital

Referring Veterinarian

Hospital Phone Number

How would you like to be informed of the results?

Fax E-mail Other

Client Information

Client Name

Contact Phone Number

Patient Information

Pet Name

DOG CAT

Breed

SEX

FS MN F M

Age / D.O.B

Patient Weight

lbs kgs

Appoinment Information

Appointment is On

Appointment Time

The Patient will come with

Owner Clinic Employee Other

Documents

X-rays

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 account Please perform at Dr Vet Animal Hospital

Has this patient has a previous CT/MRI done?

Yes No Not Sure

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.

Yes No

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.

Yes No

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.

YES NO

MRI Referral Form

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Dr.Vet Animal Hospital! "Your Pets' Ultimate Care Hub"

As Abu Dhabi’s premier veterinary hospital, we are committed to providing top-notch care and compassion to every animal we treat.

Dr.Vet Animal Hospital, Khalifa City,
Abu Dhabi

+971 (2) 412-6555

enquiries@drvet.ae

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