Please complete and submit this form to request a CT Scan or MRI for your pet. You will need to fax or email recent bloodwork as well. ALL INFORMATION MUST BE PROVIDED OR REQUEST WILL NOT BE PROCESSED. Referring Veterinarian Information Veterinarian and Dept * Doctor of Record * VSC Referring Department Client and Patient Information (Required) VSC Client # Client Last Name * Patient * Age * Gender * Species * Weight in kgs * Weight in lbs * Case History and Medical Information * Please include any sensitivity to anesthesia or any known implants or allergies. Location Which location would you like to refer to for imaging? Vienna Gaithersburg Scan Information Study Type CT MRI Spine Specifc Area - Spine Cervical Spine (C1 - T2) Thoracolumbar Spine (T3 - S3) Lumbar Spine (L3 - Sacrum) Myelogram Head/Neck Specifc Area - Head/Neck Skull Brain Nasal Cavity/Sinus Osseous Bullae Orbits Soft Tissue Neck Limb/Joints Left Side Thoracic Limb Shoulder Elbow Carpus Pelvis Stifle Tarsus Pelvic Limb Right Side Thoracic Limb Shoulder Elbow Carpus Pelvis Stifle Tarsus Pelvic Limb Soft Tissue Specifc Area - Soft Tissue Abdomen Chest Pelvis Requested Date/Time of scan Contrast Study? * Yes No Preferred Radiology Service Vetrad Sage/MRI Vets Stat Read? * Yes No Renally Compromised? * Yes (If renally compromised and receiving contrast, half-dose of contrast will be given.) No Unknown (If renal status unknown at the time of submission, imaging team MUST be notified of results at least one hour prior to scan.) Leave this field blank CAPTCHAPlease check the box to help us prevent SPAM.