Cardiac Consultation Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Name
Referring Clinic (if applicable)
Referring Veterinarian Name (if applicable)
Do you authorize Absecon Veterinary Hospital to obtain records from this hospital? If NO, please bring all patient records to your visit.
Yes
No
Do you have any other concerns today?
How is your pet doing at home?
Activity Level at Home
Inactive
1
2
3
4
Can't Seem To Rest
5
1 is Inactive, 5 is Can't Seem To Rest
What is your pet's cough frequency like, if any?
No Cough
1
2
3
4
Coughs All Day
5
1 is No Cough, 5 is Coughs All Day
How would you describe your pet's general appearance or mental activity?
Bright alert and responsive
Quiet alert and responsive
Anxious, agitated, or depressed
Dull, lethargic
How is your pet's appetite?
Normal
Decreased
Increased
How is your pet's thirst level?
Normal
Decreased
Increased
Please describe your pet's urination and bowel movements. (For urination, please indicate if the amount and frequency are normal or abnormal and describe any abnormalities. For bowel movements, please describe the amount, consistency, and color.)
If your pet is prescribed any Pre-Veterinary Pharmaceuticals (PVPs) please list them below by name, strength, dose, and frequency.
Please list all heart and/or lung medications that your pet is currently taking by medication name, strength, dose, and frequency. (Medications such as Pimobendan, Enalapril, Furosemide, Spironolactone, Sildenafil, Theophylline, Butorphanol, Benazepril, Cough Dex Tablets, etc.)
Does your pet take any other medications or supplements?
Do you need refills on any of the above medications?
When was the last time your pet had bloodwork performed?
Has your pet had an ECG?
Yes
No
I am unsure
When was the last time your pet had chest radiographs?
If your pet had any of the above diagnostics have you provided us with their records and results?
Yes
No
I am unsure
Should your pet exhibit signs of stress while in-hospital with us, do you approve for us to give an injectable medication to help relax them? (The cost is around $40)
Yes
No
Absecon Veterinary Hospital prides itself in being a teaching hospital. Do we have your permission to post your pet’s photo and/or case information for multimedia purposes for abseconvet.com and any sites related to the business?
Yes
No
*For every patient entering our practice and undergoing a diagnostic, treatment, or procedure, we obtain a CPR or DNR order from their owner.* I understand Absecon Veterinary Hospital Emergency Service (AVH) requires a CPR status prior to the start of any and all procedures so immediate action can take place in the event of cardiopulmonary arrest during, before, or after anesthesia or at any time in our care. I acknowledge that the attending veterinarian or staff members of AVH will make every effort to contact me regarding treatment in the case of this unforeseen event. The starting cost of CPR is approximately $500.00.
PROCEED with CPR (additional costs will be incurred)
DO NOT PROCEED with CPR (if your pet arrests, we will let them pass)
Signature
Submit
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