North Texas Equine Imaging Center — Referral Form

North Texas Equine Imaging

Patient Referral Form

Complete this form to refer a patient to our imaging center. Your submission will be reviewed by our scheduling team and you will receive a confirmation by email.

1Owner Info

2Referring Vet

3Patient

4Clinical

5Imaging

6Consent

7Submit

Fields marked * are required.

Client / Owner Information

Contact details for the horse's owner

Owner Contact

Owner Name *

Primary Phone *

Email Address

Street Address

City

State / Zip

Main Contact Person

Is the main contact different from the owner?

Additional Contact Information

Contact Name *

Relationship to Owner

Contact Phone *

Contact Email

Step 1 of 7

Referring Veterinarian

Information about the veterinarian submitting this referral

Contact Information

Veterinarian Name *

Clinic / Practice Name *

Direct Veterinarian Phone Number *

📞 This will be our emergency contact for this patient.

Email Address *

Radiology Report Request

All imaging studies submitted through this referral will be reviewed and reported on by Dr. Natasha Werpy, Diplomate ACVR. A formal radiology report will be sent to the referring veterinarian upon completion.

Third Party Review

Add an additional radiologist or reviewer

Third Party Contact Information

Name *

Organization / Practice

Phone

Email *

💲

Please call North Texas Equine Imaging to inquire about pricing before quoting your clients, as prices may have changed.

Step 2 of 7

Patient Information

Details about the horse being referred

Horse Details

Registered Name *

Barn Name

Breed *

Sex *

Age *

Color

Insurance

Is the horse insured?

Step 3 of 7

📋

Clinical History

All clinical information provided will be included on the patient's radiology report

📄 Important: The information you are providing here will be provided to the radiologist and included on the patient's radiology report.

Lameness Evaluation

Provide the affected limb(s), lameness timeline, grade, block response, and clinical signs for the patient.

Select Affected Limb(s)

Right Front

Left Front

Right Hind

Left Hind

Onset and Duration of Lameness

Baseline Lameness Grade

Diagnostic Anesthesia (Block) Response

Lameness Exam Findings & Clinical Signs *

Patient History

Patient History — Especially Cardiac

Surgical History

Has the patient had previous surgery?

Previous Surgery Details

Type of Surgery *

Location / Limb *

Prior & Previous Imaging

Does this patient have any prior images such as radiographs, ultrasounds, CT, or MRIs that you would like to send?

Prior Imaging Instructions

Prior imaging must be emailed separately. Please send all prior images to: office@ntxei.com. Please put the patient and owner's name in the subject line.

Prescriptions & Medications

List All Medications and Dosages the Patient Is Currently Taking *

Referring Veterinarian Signature *

Please sign below to certify this referral.

I certify that I am a licensed veterinarian that has performed a physical examination on the aforementioned patient and am submitting this referral on their behalf.

Signature *

💲

Please call NTXEI to confirm current pricing before quoting clients, as fees are subject to change.

Step 4 of 7

Imaging Services

Select all imaging services needed — each selection will expand its own question set below

Imaging Services Needed *

Select all that apply. Additional questions will appear for each service selected.

Radiograph

X-Ray Imaging

Ultrasound

Soft Tissue Imaging

Computed Tomography

MRI

Magnetic Resonance Imaging

Radiograph Details

Please answer the following questions for your radiograph order

Clinical Information

Specific Area of Interest *

Reason for Exam *

Ultrasound Details

Please answer the following questions for your ultrasound order

Clinical Information

Specific Area of Interest *

Reason for Exam *

✂️

Please Note: The patient will be shaved for better imaging acquisition. This is standard procedure for ultrasound examinations to ensure optimal image quality.

CT Details

Please answer the following questions for your CT order

💉

Please Note: Contrast will be used if indicated based on clinical findings at the time of the exam.

CT Exam Type *

Will this patient be standing or anesthetized (under general anesthesia) for the CT exam?

🐴

Standing

No anesthesia required

💉

Anesthetized

General anesthesia required

CT Exam Prescription — Standing

Select the affected limb(s) for each exam type. These exams do not require general anesthesia.

Feet

Pastern

Fetlock

Flexor Tendon Sheath

Cannon Bone

Proximal Suspensory

Knee (Carpus)

Hock (Tarsus)

Head & Neck

Cranial Neck

Skull

MRI Details

Please answer the following questions for your MRI order

🧲

Important — Shoe Removal Required: All shoes must be removed prior to drop-off for MRI. Please inform the owner that there will be an additional charge for shoe removal if performed on-site.

MRI Exam Prescription *

Select the affected limb(s) for each exam. Front limbs available up to the Knee; hind limbs up to the Hock.

Foot

Pastern

Fetlock

Cannon Bone

Knee (Carpus) — Front Only

Hock (Tarsus) — Hind Only

Stifle — Size Dependent

📏

Stifle MRI availability is dependent on horse size. Our team will confirm feasibility when scheduling.

Head — Standing

Head / Skull

Affected Area

Affected Limb(s) and Region(s) to Image *

Additional Exams / Regions Needed

Step 5 of 7

⚠️

Anesthesia Consent

Required for all procedures involving general anesthesia

📄 Important: This consent section is required if your referral includes any anesthetized CT or anesthesia-dependent MRI procedures. Please read each section carefully.

Risks of General Anesthesia in Horses

General anesthesia in horses carries inherent risks significantly greater than in small animals or humans. These risks exist even in healthy horses undergoing elective procedures:

•Cardiovascular complications — including hypotension, cardiac arrhythmias, or arrest during induction or maintenance of anesthesia.

•Respiratory complications — including hypoventilation, hypoxemia, or airway obstruction requiring intervention.

•Myopathy / neuropathy — muscle and nerve damage from prolonged anesthesia, which may cause lameness or weakness post-procedure.

•Post-anesthetic colic — gastrointestinal complications following anesthesia, including ileus or displacement.

•Death — While serious complications are rare, general anesthesia in horses carries an inherent risk that is higher than in other species. While our team takes every available precaution to ensure a smooth procedure, the possibility of a fatal outcome cannot be entirely ruled out.

Risks of Induction (Knocking Down)

The induction process involves the horse losing consciousness and becoming anesthetized. Specific risks include:

•Traumatic induction — horses may fall unpredictably, risking injury to the horse or personnel present.

•Excitement or violent response — some horses react unpredictably to induction agents, increasing the risk of self-injury.

•Aspiration — risk of inhaling gastric contents if the horse has not been properly fasted prior to induction.

Risks of Recovery

Recovery is considered one of the highest-risk phases of equine anesthesia. As the horse regains consciousness and attempts to stand:

•Traumatic recovery — horses may thrash or fall, causing fractures, lacerations, or head trauma.

•Fractures — particularly of the limbs, during attempts to stand before full neuromuscular function has returned.

•Prolonged recovery — some horses are unable to stand unassisted and may require additional intervention.

•Post-anesthetic hemorrhagic myelopathy — a rare but serious spinal cord complication that may result in permanent neurological deficits or death.

Owner / Authorized Agent Consent *

By completing this consent section, the owner or authorized agent confirms that:

I have been informed of and understand the risks of general anesthesia, induction, and recovery as described above. I consent to the proposed procedure(s) and understand that North Texas Equine Imaging and its staff cannot be held liable for complications arising from general anesthesia. The patient has been appropriately fasted prior to the procedure per the instructions provided by the referring veterinarian or North Texas Equine Imaging.

Printed Name *

Relationship to Owner *

Signature *

Learning & Social Media Consent

Consent for learning and social media?

No media will be used that identifies the patient or owner.

Step 6 of 7

✅

Review & Submit

Confirm your referral details and submit

What Happens After You Submit

📄

A PDF of this referral will be automatically generated and emailed to our clinic and scheduling team.

📞

Our team will contact you within 1 business day to confirm the appointment time.

🔒

Your data is secure. All submissions are encrypted and stored in compliance with HIPAA standards.

Final Confirmation

Date of Submission

Step 7 of 7

✅

Referral Submitted!

Your confirmation number is . Submitted on .

Our scheduling team will contact you within 1 business day to confirm the appointment. A copy of this referral has been sent to the email address on file.