Neurology MRI/CT Form – FREDERICK

Click HERE for a printable PDF version of this form.

Please submit or bring a printed copy of this completed form with you to your pet’s appointment.

Please contact us at 301.200.8185 with any questions.

Owner Name
Date / Time

Magnetic Safety Screening

Metal/magnetic materials may interfere with advanced imaging techniques and the safety of your pet; please answer the following to the best of your knowledge

Does your pet have any metallic surgical implants? (e.g. orthopedic implants, staples/clamps, other)
If not, we will provide a bland diet while your pet is in hospital.
Has your pet ever been injured by a metallic object? (e.g. BB pellet, bullet, shrapnel, etc.)
Does your pet have a pacemaker or other cardiac implant?
Is your pet microchipped?

Risks/Complications

  • Anesthesia is required for MRI/CT procedures and injectable contrast agents may be used.
  • Recovery time from anesthesia is variable, and my pet will be released from the hospital when it is safe and approved by the anesthesia team. This typically may take a few hours but may require longer time in the hospital in rare cases.
  • There are risks associated with anesthesia, the use of contrast agents, and advanced imaging procedures; these complications are extremely rare. They may include, but are not limited to: equipment malfunction, skin burns, organ failure, cardiac or respiratory arrest, obstructed airway, regurgitation/aspiration, allergic reactions, and death.
  • All metallic items (e.g. collars, tags, and medical devices such as Freestyle Libre transdermal glucose monitors) must be removed prior to advanced imaging procedures.
  • To allow proper anesthesia monitoring, certain hair must be trimmed (a patch on 1-2 legs and a larger patch on the left or underside of the chest). If a spinal tap is performed, an additional small patch will be shaved on the back of the neck or lower back.
  • All of these factors are taken into consideration when making anesthetic plans and deciding to pursue advanced imaging procedures to minimize risk of complications.

Use of Images

  • Diagnostic images, videos, and photographs of my pet may be shared or used for educational purposes.
Consent
I have answered these questions to the best of my ability. I understand the risks and potential complications as described above and have/will read the separate Anesthesia Consent Form. I authorize my pet to undergo advanced diagnostic imaging (MRI/CT).