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Advanced Imaging Request Form

Make an imaging referral below

Please see below to find out when the mobile MRI unit will be visiting Earlswood Veterinary Referrals in 2022. To request an appointment please fill in the form on this page or contact Becky Miskimmin, our referral administrator.

  • 4th January 2022
  • 18th January 2022
  • 1st February 2022
  • 15th February 2022
  • 1st March 2022
  • 15th March 2022
  • 29th March 2022
  • 12th April 2022
  • 26th April 2022
  • 10th May 2022
  • 24th May 2022
  • 7th June 2022
  • 21st June 2022
  • 5th July 2022
  • 19th July 2022
  • 2nd August 2022
  • 16th August 2022
  • 30th August 2022
  • 13th September 2022
  • 27th September 2022
  • 11th October 2022
  • 25th October 2022
  • 8th November 2022
  • 22nd November 2022
  • 6th December 2022
  • 20th December 2022

Advanced Imaging Request Details

Type of Imaging Request*

Practice Details

Patient Details

Urgent Report Needed*

Imaging Request

Type of Imaging*

Body Areas







Imaging Safety Questionnaire

Heart disease/pacemaker*

Renal disease*

Known adverse reactions to medications*

Surgery within the previous two months*

Metal fragments / implants any location*

Pregnancy*

Endocrine disease, bleeding disorder, neoplasia*

Epilepsy*

Security Question
Note: By submitting this form you confirm that you are a qualified veterinary surgeon who has obtained consent from the patient’s owner to act on behalf of the animal described above; that the owner has given permission for the administration of an anaesthetic/sedative to the above animal at the imaging location together with any other procedures that may prove necessary; and that the owner understands that in the unlikely event of an emergency or where additional pain relief or sedation may be required, the imaging branch will act in the best interests of the patient.; that the owner has agreed that they have understood that medicines may be used which are not licensed for use in dogs and cats; and that in the event that you cannot be contacted on the above number, you understand that the imaging branch will act in the best interests of the patient.