Cardiac Consultation Referral Form

Cardiac Consultation Referral Form

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 if you, the referring DVM, would like to discuss the final report with your client or if you would like Veterinary Diagnostic Centers to discuss it with them:

Veterinary Diagnostic Centers Referring Veterinarian Practice Partnership Program

We are a Fear Free facility and recommend that an oral sedative be prescribed for the selected ultrasound procedure, although it is not mandatory. You can refer to our suggested oral sedative protocols. **Please note – Although we do have injectable sedatives available at our facilities, we CANNOT administer these to echocardiogram patients due to effects on the hemodynamics. 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 aware of before the appointment? (This will be kept confidential)

Do you recommend expediting this report to ensure results are received today? The typical turnaround time is the next business day. If so, we will seek approval from the pet owner as there is an additional cost.

Yes No

If the Comprehensive Cardiology Consultation is selected, thoracic radiograph interpretation is an important part of the echocardiogram report. Thoracic radiographs (the more recent, the better) should be sent with the medical history for submission. DICOM files are highly preferred over JPEG. Please indicate if you will be sending thoracic radiographs prior to the patient’s appointment:

Yes No

**Please note – if radiographs are not provided to us, we may perform the radiographs during the patient’s appointment to complete the submission. There will be an additional charge to the client that we will have approved prior to performing. We cannot perform radiographs in our Chicago and Schaumburg locations.**

Please upload medical records, blood work/labs, radiographs, and any previous referral reports:

Client Information

Client Full Name:

Client Phone Number:

Patient Information

Patient Name:

Patient Weight (Kg):

Patient Age:

Patient Sex:

Species:

Breed:

Referral Information

Referring Veterinarian Hospital Name:

Referring Veterinarian Name:

Email or Fax number where you would like the results sent to:

Medical Information

History/chief complaint:

Is there any specific information that you would like the report to contain?

List any concurrent illnesses:

List all diagnostics that have been completed and any pertinent laboratory results or reports:

List any medications/supplements that the patient is currently taking, including frequency and dosage:

List any medications/supplements that have been finished or discontinued for the current chief complaint:

Veterinary Diagnostic Centers