Basic Echocardiogram Form

Please click on the appropriate location.

Mokena, IL
Chicago, IL
Crown Point, IN

For these reports the default is that our veterinarian will contact the pet owner to discuss the findings. That being said if you prefer we can send the report to you to discuss with the client yourself please let us know below.

Please indicate who you would like to have discuss with owner:

Veterinary Diagnostic Centers Referring Veterinarian

We are a Fear Free facility. We suggest that an oral sedative be prescribed but this is not mandatory. If you and the family believe this is not necessary we can do without. For suggested protocol please refer to our Referring Vets dropdown. Please indicate whether an oral sedative will be prescribed.

Yes No

Are there any matters concerning the client or the pet that we should be made aware of (will be kept confidential)?

Please upload medical records, labs, images, and previous referral reports

Do you recommend that this report be expedited to obtain results within 4-5 hours instead of 24 hours? If so, we will seek approval with the pet owner as there is additional cost.

Yes No

Client First Name

Client Last Name

Client Phone

Patient Name

Patient Weight

Patient Age

Referring Veterinarian Hospital

Referring Veterinarian

Email or Fax number where you’d like results sent

Reason for the Exam

Are there any concurrent illnesses?

Differential List

Are there any specific organs you’d like us to focus on?

List medications and supplements including dosage and frequency that patient is currently on

List any medications that the patient has been on for this problem that have been discontinued

Other comments that you’d like to share

For these reports the default is that our veterinarian will contact the pet owner to discuss the findings. That being said if you prefer we can send the report to you to discuss with the client yourself please let us know below.

Please indicate who you would like to have discuss with owner:

Veterinary Diagnostic Centers Referring Veterinarian

Yes No

Are there any matters concerning the client or the pet that we should be made aware of (will be kept confidential)?

Please upload medical records, labs, images, and previous referral reports

Do you recommend that this report be expedited to obtain results within 4-5 hours instead of 24 hours? If so, we will seek approval with the pet owner as there is additional cost.

Yes No

Client First Name

Client Last Name

Client Phone

Patient Name

Patient Weight

Patient Age

Referring Veterinarian Hospital

Referring Veterinarian

Email or Fax number where you’d like results sent

Reason for the Exam

Are there any concurrent illnesses?

Differential List

Are there any specific organs you’d like us to focus on?

List medications and supplements including dosage and frequency that patient is currently on

List any medications that the patient has been on for this problem that have been discontinued

Other comments that you’d like to share

For these reports the default is that our veterinarian will contact the pet owner to discuss the findings. That being said if you prefer we can send the report to you to discuss with the client yourself please let us know below.

Please indicate who you would like to have discuss with owner:

Veterinary Diagnostic Centers Referring Veterinarian

Yes No

Are there any matters concerning the client or the pet that we should be made aware of (will be kept confidential)?

Please upload medical records, labs, images, and previous referral reports

Do you recommend that this report be expedited to obtain results within 4-5 hours instead of 24 hours? If so, we will seek approval with the pet owner as there is additional cost.

Yes No

Client First Name

Client Last Name

Client Phone

Patient Name

Patient Weight

Patient Age

Referring Veterinarian Hospital

Referring Veterinarian

Email or Fax number where you’d like results sent

Reason for the Exam

Are there any concurrent illnesses?

Differential List

Are there any specific organs you’d like us to focus on?

List medications and supplements including dosage and frequency that patient is currently on

List any medications that the patient has been on for this problem that have been discontinued

Other comments that you’d like to share

Mokena, IL
Chicago, IL
Crown Point, IN

For these reports the default is that our veterinarian will contact the pet owner to discuss the findings. That being said if you prefer we can send the report to you to discuss with the client yourself please let us know below.

Please indicate who you would like to have discuss with owner:

Veterinary Diagnostic Centers Referring Veterinarian

Yes No

We have only needed to administer an injectable sedative to less than 1.0% of our patients. Please indicate if you believe, due to aggression or other behavioral concerns, that this will need to be done with this patient.

Yes No

Are there any matters concerning the client or the pet that we should be made aware of (will be kept confidential)?

The internal medicine specialists that will completing the consultation require updated bloodwork within 4 weeks. If this is not provided in the records received we will need to collect and submit. If you have any reason that you do not want us to collect and submit please note here.

Please upload medical records, labs, images, and previous referral reports

Do you recommend that this report be expedited to obtain results within 4-5 hours instead of 48 hours? If so, we will seek approval with the pet owner as there is additional cost.

Yes No

If, during the ultrasound, we encounter a structure that we believe would be useful perform an ultrasound-guided aspirate and submit for cytology do we have your approval? We will discuss cost, risks, and value of the procedure to the pet owner and obtain consent.

Yes No

Client First Name

Client Last Name

Client Phone

Patient Name

Patient Weight

Patient Age

Referring Veterinarian Hospital

Referring Veterinarian

Email or Fax number where you’d like results sent

Reason for the Exam

Are there any concurrent illnesses?

Differential List

Are there any specific organs you’d like us to focus on?

List medications and supplements including dosage and frequency that patient is currently on

List any medications that the patient has been on for this problem that have been discontinued

Other comments that you’d like to share

For these reports the default is that our veterinarian will contact the pet owner to discuss the findings. That being said if you prefer we can send the report to you to discuss with the client yourself please let us know below.

Please indicate who you would like to have discuss with owner:

Veterinary Diagnostic Centers Referring Veterinarian

Yes No

Are there any matters concerning the client or the pet that we should be made aware of (will be kept confidential)?

Please upload medical records, labs, images, and previous referral reports

Do you recommend that this report be expedited to obtain results within 4-5 hours instead of 24 hours? If so, we will seek approval with the pet owner as there is additional cost.

Yes No

Client First Name

Client Last Name

Client Phone

Patient Name

Patient Weight

Patient Age

Referring Veterinarian Hospital

Referring Veterinarian

Email or Fax number where you’d like results sent

Reason for the Exam

Are there any concurrent illnesses?

Differential List

Are there any specific organs you’d like us to focus on?

List medications and supplements including dosage and frequency that patient is currently on

List any medications that the patient has been on for this problem that have been discontinued

Other comments that you’d like to share

For these reports the default is that our veterinarian will contact the pet owner to discuss the findings. That being said if you prefer we can send the report to you to discuss with the client yourself please let us know below.

Please indicate who you would like to have discuss with owner:

Veterinary Diagnostic Centers Referring Veterinarian

Yes No

Are there any matters concerning the client or the pet that we should be made aware of (will be kept confidential)?

Please upload medical records, labs, images, and previous referral reports

Do you recommend that this report be expedited to obtain results within 4-5 hours instead of 48 hours? If so, we will seek approval with the pet owner as there is additional cost.

Yes No

Client First Name

Client Last Name

Client Phone

Patient Name

Patient Weight

Patient Age

Referring Veterinarian Hospital

Referring Veterinarian

Email or Fax number where you’d like results sent

Reason for the Exam

Are there any concurrent illnesses?

Differential List

Are there any specific organs you’d like us to focus on?

List medications and supplements including dosage and frequency that patient is currently on

List any medications that the patient has been on for this problem that have been discontinued

Other comments that you’d like to share

Veterinary Diagnostic Centers

Please click on the appropriate location.

For these reports the default is that our veterinarian will contact the pet owner to discuss the findings. That being said if you prefer we can send the report to you to discuss with the client yourself please let us know below.

For these reports the default is that our veterinarian will contact the pet owner to discuss the findings. That being said if you prefer we can send the report to you to discuss with the client yourself please let us know below.

For these reports the default is that our veterinarian will contact the pet owner to discuss the findings. That being said if you prefer we can send the report to you to discuss with the client yourself please let us know below.

For these reports the default is that our veterinarian will contact the pet owner to discuss the findings. That being said if you prefer we can send the report to you to discuss with the client yourself please let us know below.

For these reports the default is that our veterinarian will contact the pet owner to discuss the findings. That being said if you prefer we can send the report to you to discuss with the client yourself please let us know below.

For these reports the default is that our veterinarian will contact the pet owner to discuss the findings. That being said if you prefer we can send the report to you to discuss with the client yourself please let us know below.

Address

Contact

Hours

© 2024 Veterinary Diagnostic Centers| Powered by Full Slice | Privacy Policy