Vet Referral for Advanced Imaging Services

Type of Scan*

CT
MRI
Ultrasound

Area(s) to be scanned*

Brain
Cervical Spine
Thoracic Spine
Lumbar Spine
Head
Abdomen
Thorax
Shoulder
Elbow
Carpus
Pelvis
Stifle
Tarsus
Other

Specify Location*

Specify Side*

Right
Left

Area to Be Scanned*

Reason for requesting scan*

Please be as detailed and comprehensive as possible.

Additional medical history pertinent to the case or anesthesia safety

Is an examination and consultation with one of the Tier 1 VMC doctors or specialists desired prior to the advanced imaging?*

Yes
No

Referring Clinic*

Referring DVM*

Email Address*

Client Name*

First Last

Client Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Client Email*

Client Phone*

Patient Name*

First

Patient Species*

Canine
Feline

Patient Breed*

Patient Age*

Patient Weight*

Check the box below to indicate that you have read and agree to the terms listed.*

I have read and agree to the terms listed below.

1. Due to the need for injectable and/or gas anesthesia for advanced imaging and the use of contrast agents, a current (within 1 month) CBC/biochemistry and urinalysis is required. Risks of using contrast agents may lead to acute renal failure or anaphylactic shock.

2. All medical records and current bloodwork/urinalysis are required prior to scheduling imaging. Please send all information to info@tier1vet.com.

3. As the referring veterinarian, I understand that without an examination and consultation with a Tier 1 doctor or specialist, I take full responsibility for the general health of this patient and that this patient is safe to undergo anesthesia. I also understand that I am responsible for the decisions regarding what imaging modality to use and what anatomy to image. Tier 1 will not be discussing the imaging results with the client or making recommendations and will forward the results to me as soon as they are available.

4. To improve efficiency, Tier 1 will communicate only with the doctor/clinic requesting the imaging and not the client.

Name

This field is for validation purposes and should be left unchanged.

6623 East Blue Lupine Rd, Palmer, AK 99645

6623 East Blue Lupine Road, Palmer, AK 99645

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