Cardiology Client Referral Form

If your pet has not been previously seen for or been diagnosed with a cardiologic condition, please fill out the New Client Form instead.

Client Information

First Name *

Last Name *

Phone *

Street Address

City

State/Province

ZIP / Postal Code

Patient Identification

Patient Name First and Last Name *

Clinic/Patient Number

Species *

Breed *

Gender *

Weight

Weight Unit

Year(S) Old *

Month(s) Old

Week(s) Old

Date of Birth

Referring Clinic

Referring User

Referring Clinic Email

Reason for cardiac evaluation *

Have we performed a formal consultation on this patient before?YesNo

If Yes, Date of last cardiac ultrasound

Relevant history and current clinical signs

Gallop/arrhythmia/other abnormal heart sounds? If yes, please specify.

Relevant radiographic and/or laboratory findings

Current medications (include mg or mg/kg. frequency, start date)

Additional comments/questions (optional)

Blood pressure: date obtained and method

Private comments to the cardiologist (not included in final report)

Blood pressure: date obtained and method

Private comments to the cardiologist (not included in final report)

Is an anesthetic procedure being considered?YesNoUnknown

Upload DICOM and NON-DICOM files (PDF, AVI, JPG, PNG, etc.)

No file chosen

Additional files attached with this form

Scheduling policy: Client must complete an initial consultation with our doctors and any required diagnostics before scheduling the echocardiogram.

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Client Information

Patient Identification

Referring Clinic

We are here for you and your pets!