MRI Form

MRI Form Sept 2024

Date of MRI

AM or PM?

Area of Interest to Image

Horse Name

Age *

Breed *

Sex *

Color *

Owners Name

Mailing Address *

Mailing Address

City

State/Province

Zip/Postal

Country

Cell Phone

Email Address

Referring Veterinarian:

Name on Credit Card

Credit Card Number *

Expiration Date *

CVV (security code) *

Paragraph

Note:

It is a VEI policy to have credit card information prior to the MRI examination date. Your credit card will be debited at the end of the day that the horse was discharged, unless you prefer to pay by check in person at the time of the exam. By signing this information form, you authorize such a credit card debit (unless paid by check at the time payment is due).

The fee for a MRI of two feet is $3570: $1,830 to VEI and $1740 to Marion duPont Equine Medical Center. The fee for a MRI of one foot is $2275: $1005 to VEI and $1311 to Marion duPont Equine Medical Center.

The fee for an additional area of interest is $1295 to Marion duPont Equine Medical Center. There may be an additional fee for MRI foot preparation and radiograph from EMC.

Please be sure to pay the Marion duPont Scott Medical Center directly prior to discharge.

Signature

Clear

Date

Patient Preparation for the MRI Procedure:

• MRI examinations require that the horse shoes and nails be carefully removed from the front or hind feet depending on the area being imaged.
• Please arrive 15 minutes before schedule time for shoe removal.
• Horses should arrive at the EMC by 7:45-8:00 A.M. for morning MRI or 12:00-12:15PM for afternoon MRI on the date of the scheduled examination and check in with admissions at the EMC. A doctor from Virginia Equine Imaging will be in admissions at the EMC when you arrive.
• Next, the patient will be brought into the main patient treatment room for preparation for the MRI series.
• The feet will be thoroughly cleaned with soap and water, and if there are any questions about having retained metal from nails in the feet, a radiograph will be taken of each foot. There will be an additional fee of $55.00 per foot for the radiograph, payable to Morven.*
• Our doctor will sedate the horse prior to entering the MRI room and the patient will be sedated as necessary throughout the procedure.
• The procedure usually takes 3-4 hours depending on how cooperative the patient is in the magnet.
• Following the completion of the MRI series, the patient will be removed from the MRI room and put into a stall until they are safely able to load onto the trailer.
• The images will be read by Dr. Kent Allen and VEI following the procedure.
• The patient will either return to VEI for additional diagnostics and workup or the information will be forwarded to the referring veterinarian.
• Please Note: Access to the MRI must be strictly controlled because of potential adverse effects of visitors on the magnet and the magnetic field on visitors. For this reason, owners are prohibited in the magnet. However, if the owner insists on staying with the horse during the acquisition of MR images, a consent form must be signed prior to entering the magnet room.

MRI Location:
Marion duPont Scott
Equine Medical Center
17690 Old Waterford Rd at Morven Park
Leesburg, VA 20177

If you are in need of directions to the Marion duPont Scott Equine Medical Center at Morven Park, they can be found on the internet at http://emc.vetmed.vt.edu/directions.html or you can reach them at 703-771-6800.