Stack Vet - Cardiology Referral Form for Veterinarians

1

Today’s Date

Date

2

Email* This field is required.

example@example.com

3

Patient Information* This field is required.

Patient Name

Weight

Age

Breed

4

Client Information

Client Name

Phone Number

5

Hospital you are referring to (circle)

Briar Patch Veterinary Hospital

Elemental Pet Vets

Stack Veterinary Hospital (Velasko Rd)

6

Please send last 12 months records including radiographs and current blood work.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

7

Referring Vet Details

Referring Vet Name / Hospital Name

Referring Hospital Phone Number

Email Address

8

Reason for Referral (To be filled out by referring vet)

New Heart Murmur

Heart Murmur Worsening in Intensity

Arrhythmia

Collapse/Syncope

Cough

It’s complicated (Please describe):

9

It's Complicated

10

Current Medications (please include flea/tick/heartworm preventatives):

11

Do you require anesthesia recommendations for this patient?

Yes

No

12

Will the patient require sedation due to temperament?

Yes

No

13

If yes, please consider prescribing gabapentin and/or trazodone to give prior to the appointment.

14

Please fax or email to hospital you are referring to:

Briar Patch Vet Hospital

Phone: 607-272-2875

Email: info@briarpatchvet.com

Elemental Pet Vets

Phone: 607-697-0443 fax

Email: elementalpetvets@outlook.com

Stack Vet Hospital

Phone: 315-478-2432

Email:amanda@stackvet.com