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
Were nerve blocks performed? Yes
No
If yes, which nerve blocks were performed?
What was the response (percentage of improvement)?
Date and location of latest nerve block performed (please note that artifacts can interfere with image interpretation)
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 you chose "other," please give specific description
Are the horse's shoes removed? Yes
No
Does the horse have orthopedic/metal implants? Yes
No
Physical Examination Findings by Referring Veterinarian
Heart Normal
Abnormal
Lungs Normal
Abnormal
Temperature Normal
Abnormal
Were any other health problems noted? Please describe.
Has the horse been given previous sedation, nerve blocks or anesthesia? Yes
No
Drug names/doses used
Were there any adverse reactions to previously performed sedations, nerve blocks or anesthesia? Yes
No
If yes, what was the suspected diagnosis for the reaction?
Date and type of last vaccination
Special concerns and/or considerations