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Please use this form to submit a referral request to NC State Veterinary MRI.

This service is for veterinarians only – clients seeking medical information should contact their regular veterinarian for assistance.

If you would like to make a referral to one of the VH Services and you do not need to talk to a VH clinician, you can use this form to submit the client and patient information. Please indicate on the form if you have told the client to call the VH, or if you would like us to call them. Please provide a summary of the history of the case so that we can be prepared to provide the patient with the appropriate care. Please send or fax supporting information. Please send radiographs or other images with the client or by submitting directly to us through eFilm (see instructions on main Information for Referring Veterinarians page).

 NOTE:
The NC State Veterinary MRI only accepts American Society of Anesthesiologist Status I & II patients for outpatient referral.
Upon receiving referral information and medical records as outlined below, an ASA determination will be made by the Anesthesiologist. For optimal medical care and patient management, ASA III – V patients must be referred through primary VH services (e.g. Neurology, Internal Medicine, etc).

 American Animal Hospital Association Preanesthetic Evaluation

Human ASA Physical Status Classification System

If this is an EMERGENCY REFERRAL (i.e. needs to be seen within 24hrs), please call the appropriate service immediately after submitting the information below.

Fields marked with an * are required

Veterinarian Contact Information

Owner Contact Information

Patient Information

  • For case consults, please contact appropriate VH service

Clinical History*

* Please note that patient history, bloodwork and MRI request must be received by the MRI director a minimum of 24hrs prior to the scheduled MRI Scan.
Outpatients are required to have a CBC and chemistry panel within 7 days of MRI scan. A Big 4 may be performed the morning of the MRI scan based on the patient's age and health condition; this will be at the discretion of the clinician and can be performed by the NC State MRI team at no additional cost. Please send copies of all recent lab work performed in addition to the CBC and chemistry panel. The MRI clinician will contact the rDVM if additional bloodwork is needed prior to anesthesia. 

Medical Record Data Accompanying Referral
(please fax 919-513-8838 or email NCStateVetMRI@ncsu.edu)

Medical Records

Vaccination History

NC State Estimate provided to owner (if any):