ECG Consultation Request

When referring your patient to our hospital, please complete this form along with all pertinent medical records.

Date of referral

Today

REFERRING VETERINARIAN INFORMATION

Referring hospital*

Referring DVM*

Phone Number*

Email*

Systolic BP result *

TT4 result *

ProBNP result *

Creatinine result *

Heartworm test result *

Completed Diagnostics - Please summarize results of any other completed diagnostics. Write "none" if N/A. *

Pending Diagnostics - Please list any pending diagnostics. Write "none" if N/A. *

Planned Diagnostics - Please list any planned diagnostics not yet in progress or performed. Write "none" if N/A. *

Please describe any relevant prior treatments the patient received for the current clinical signs. *

Please list the patient's current cardiac medications. Include drug name, dosage, and administration. *

Please describe the patient's response to these cardiac medications, if any. *

Please list any other medications the patient is taking, including supplements. Include drug name, dosage, and administration. *

Do you need comments on anesthesia for a procedure planned in the short-term future? *

Yes
No

Is there any additional medically pertinent information to share? If yes, please explain. *

Are there any specific clinical questions or concerns you would like addressed in this report? *

Please Upload Medical Records / Study Reports *

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *