Standing MRI Referral Form

Please complete the online form and click the "Submit" button at the bottom of the page. You will receive a confirmation email message immediately after submitting your referral form. 

If you have any questions or problems completing this form, please contact vmccorrespond@usask.ca.
 
Fields marked with a red asterisk must be completed before submission.

Confirmation Email Address:?
Referring Veterinarian's Information
Name
Phone
Fax
Email
Hospital name
Address
City/town
Province
Postal code
Client Information
Client name
Address
City/town
Province
Postal code
Preferred phone Cell
Home
Work
Preferred #
Alternate phone Cell
Home
Work
Alternate #
Client email
Are you insured for imaging? Yes
No
If yes, please provide name of insurance company.
Phone
Policy number
Patient Information
Patient name
Breed
DOB
(01 Jan 2014)
Gender Mare
Stallion
Gelding
What do you use your horse for?
History and Presumptive Diagnosis
Clinical history
Lameness localized to
Grade of lameness
Nerve Blocks
Were nerve blocks performed? Yes
No
Palmarodigital nerve block? Yes
No
Response to palmarodigital nerve block
IA distal interphalangeal nerve block? Yes
No
Response to IA distal interphalangeal nerve block
IA proximal interphalangeal nerve block? Yes
No
Response to IA proximal interphalangeal nerve block
Abaxial nerve block? Yes
No
Response to abaxial nerve block
IA fetlock nerve block? Yes
No
Response to IA fetlock nerve block
Low four point nerve block? Yes
No
Response to low four point nerve block
High four point nerve block? Yes
No
Response to high four point nerve block
Yes
No
Response to IA carpus nerve block
List any other nerve blocks that were performed on this patient.
Were radiographs taken of the area to be imaged in the MRI? Yes
No
If yes, what were the radiographic findings?
Will the radiographs be available for review? Yes
No
Medical image #1
Medical image #2
Medical image #3
Leg to be imaged Left front
Left hind
Right front
Right hind
Area to be imaged Foot
Fetlock
Distal suspensory
Proximal suspensory
Carpus
Tarsus
Other
If other, please specify:
Have the horse's shoes been removed? Yes
No
Physical Examination Findings by Referring Veterinarian
Heart Abnormal
Normal
Lungs Abnormal
Normal
Temperature Abnormal
Normal
Any other health problems noted?
No
Yes
If yes, please name the drugs used and their dosage:
Did the horse have any adverse reactions to previously performed sedations, nerve blocks or anesthesia? Yes
No
What is your suspected diagnosis for this reaction?
Date of last vaccination:
(01 Jan 2014)
What vaccines were given?