University of Minnesota
University of Minnesota - Veterinary Medical Center
http://www.vmcavid.umn.edu/

Advanced Veterinary Imaging Direct - Request

Referring DVM Information
Fields marked with a * are required.
Client/Patient Information
 
 
Fields marked with a * are required.
Requested Procedure

CT scan procedures require general anesthesia.
Pertinent History for Anesthesia Management: *
 
 
 
 
 
 
Is previous anesthesia history available for this patient? *
 
Can you provide a CBC and chemistry panel within 2 weeks? *
Blood work is required for anesthesia or sedation: view preparation for general anesthesia.
 
If No, do you want the VMC to perform current bloodwork for CBC and chemistry panel?
 
Fine needle aspirate & core biopsies: *
  • Current (within 72 hours) platelet count required for fine needle aspirate
  • Current platelet count and PT/PTT required for core biopsies
Should fine needle aspirate be performed?
Should core biopsies be performed?
If fine needle aspirate or core biopsies are anticipated, do you want the VMC to perform the platelet count and coagulation panel?
 
The following questions are related to intravenous contrast administration
Does the patient have seizures? *
 
Does the patient have a history of severe or end-stage renal failure? *
 
Does the patient have cardiac disease? *
 
Does the patient have a history of a contrast reaction? *
 
Any prior surgery/intervention at or near the procedure site? *
Any scars within the imaging field may be clipped and marked for the CT procedure
 

MRI procedures require general anesthesia.
Pertinent History for Anesthesia Management: *
 
 
 
 
 
 
Any Previous Anesthesia History (complications or problems) available? *
 
Can you provide CBC and chemistry panel? *
Blood work is required for anesthesia or sedation; view preparation for general anesthesia
 
If No, do you want the VMC to perform current blood work for CBC and chemistry panel?
 
This Question is Related to Intravenous Contrast Administration:
Does the patient have a history of severe or end-stage renal failure? *
 
Does the patient have any metallic implants or surgical staples/clips *
 

Cystourethrography Requires:
  • General anesthesia and abdominal prep, including 24 hours fasting and enema to be performed by VMC in the morning.
Intravenous Urography (IVU) Requires:
  • Abdominal prep, including 24 hours fasting.
  • A current BIN, CREAT, and urine specific gravity.
  • Dehydration is a contraindication for an IVU.
Upper Gastrointestinal (GI) Series Requires:
  • Abdominal Prep, including 24 hours fasting and enema to be performed by VMC in the morning
Is there suspected a GI perforation? *
 
Pertinent History for Anesthesia Management: *
 
 
 
 
 
 
Any previous anesthesia history (complications or problems) available? *
 
Can you provide CBC and chemistry panel? *
 
If No, do you want the VMC to perform current blood work for CBC and chemistry panel?
 
Is there a suspected esophageal perforation? *
 
The following questions are related to intravenous contrast administration
Does the patient have seizures?
 
Does the patient have a history of severe or end-stage renal failure?
 
Does the patient have cardiac disease?
 
Does the patient have a history of a contrast reaction?
 
Are ectopic ureters suspected? *
 

Pertinent History for Anesthesia Management: *
 
 
 
 
 
 
Any previous anesthesia history (complications or problems) available? *
 
Do you want the VMC to perform the radiographs? *
 
Fine needle aspirate & core biopsies: *
  • Current (within 72 hours) platelet count required for fine needle aspirate
  • Current platelet count and PT/PTT required for core biopsies
Should fine needle aspirate be performed?
Should core biopsies be performed?
If fine needle aspirate or core biopsies are anticipated, do you want the VMC to perform the platelet count and coagulation panel?
 


 
Who should receive an email copy of this referral?
 
Please Note, If you elect to send an email copy to your client they will only recieve the referring DVM and client/patient information.