Advanced Imaging Request Form

Make an imaging referral below

The mobile MRI unit will be visiting Earlswood Veterinary Referrals every Monday-Wednesday excluding Bank Holidays. To request an appointment please fill in the form on this page or contact Becky Miskimmin, our referral administrator.

 

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.