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Specialized veterinary imaging

Request an MRI

Complete the referral form so the MEDHOUSE team can review the case and get back to you.

No login requiredSimple, secure submission

About 5 minutesYour progress is saved locally

Step 1

Request Information

The MRI procedure will be performed under General Anesthesia to ensure your pet remains completely still during the scan, which typically takes between 40 to 60 minutes.\n\nWe kindly ask you to complete the following form carefully and thoroughly, as the information you provide is essential for us to determine the most suitable anesthesia plan and ensure your pet receives the best possible care based on their specific needs and the nature of the MRI.\n\nThank you for your cooperation and trust.

Email*

Please complete this field correctly.

Step 2

Pet’s Info

Name*

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Sex*

MaleFemale

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Specie*

DogCat

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Breed*

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Age*

put age in "months old" or "years old" ie: 18 months or 1.8 years

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Pet Weight in kg

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Owner*

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Owner Phone Number*

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Referral Doctor*

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Step 3

Medical History

Any Existing or Previous Health Problem?*

If yes, Please specify (ex: heart, kidney...)

NoYes

Please specify

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Ever encoutered any sickness before*

If yes, please specify

NoYes

Please specify

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Ever entered a hospital for a medical reason before?*

If yes, please specify

NoYes

Please specify

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Any operations done before*

If yes, please specify

NoYes

Please specify

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Step 4

Condition

When did his problem start?*

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Describe what usually happens*

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Current Pet Status*

AwakeSleepyDizzyDisorientedUnresponsive/Coma

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Activity*

NormalIncreased ActivityDecreased Activity

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Urination*

Normal urination (pet pees on their own without help)Urinary incontinence (accidental urine leakage without control)Manual bladder expression (pressing your pet’s belly to help them urinate)Other

Please specify

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Urine Color*

Normal Urine (Clear Yellow)Dark YellowBrownish / BloodySmellyOther

Please specify

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Any current gastro-intestinal problems?*

NoVomitingDiarrhea

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Any Affected Paws? (Front limbs? Back limbs? All limbs? Limbs from one side? One Limb? None)*

NoFront limbsBack limbsAll limbsLimbs from one sideOne Limb

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Paws Movement*

Normal movementsCan't move them at allSubtle movements / Deficit in movementDragging pawsUncoordinated movements

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Is/Was the Pet on any Medication*

If yes please specify in "other"

NoYes

Please specify

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Any recent prescription by the recommended Doctor? If yes, Please Upload here Upload filesPDF, JPG, PNG, WEBP, MP4 or MOV · up to 25 MB each

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Any Laboratory tests done? Blood tests/ Xrays/ Echography... Upload filesPDF, JPG, PNG, WEBP, MP4 or MOV · up to 25 MB each

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Any Captured Photos/Videos of the Condition? Upload filesPDF, JPG, PNG, WEBP, MP4 or MOV · up to 25 MB each

Please complete this field correctly.

Final step

Review your MRI request

Please check the information before submitting.

I confirm that the information provided is accurate to the best of my knowledge.

✓

Request received