English | AniCura AOI - Animal Oncology and Imaging Center

Patient data

Breed

Age

Sex male female intact/neutered/spayed

Weight

Owner data

Name

E-mail

Address

Phone number

Referring Veterinarian

Practice Name

Address

E-mail

Please send the pertinent medical records, radiographs and lab resluts.

Reason for Referral

Animal Temperament

Pertinent History

Pertinent Lab Results

Current Medication / Treatment

Presumptive diagnosis / rule-outs

Previous anesthesia or surgery? Yes No

Are there any metallic implants in this patient? Yes No

Is the patient ambulatory? Yes No

Scan Requested RX US CT MRI

Regions

General Information

General anesthesia is required for all CT and MRI examinations. All patients must be fasted for at least 12 hours (if the clinical condition of the patient allows this). A written report will be sent via email or fax within 24h following the scan.

The Referral form must be received prior to the appointment to facilitate safe anesthesia planning.

Please Note: It is very important that you ore one of your associates is available by phone the day of the scan.

Data privacy I have read and acknowledge the privacy policy.