Southglen - Cardiac Ultrasound Referral

Cardiac Ultrasound Referral Form

Any information that is not on the referral document will not be sent to the radiologist and therefore a less complete study will result. Dr. Litchfield will not be going over results with clients.
DATE

Month Day Year
Date
REFERRING VETERINARIAN INFORMATION
REFERRING HOSPITAL
rDVM NAME
PHONE NUMBER
FAX NUMBER
EMAIL
example@example.com
CLIENT INFORMATION
OWNER'S NAME

First Name Last Name
CO-OWNER'S NAME

First Name Last Name
ADDRESS

Street Address

Address Line 2

City Province

Postal Code
PHONE NUMBER
SECONDARY PHONE NUMBER
EMAIL
example@example.com
PATIENT INFORMATION
PET NAME
AGE
SPECIES/BREED
GENDER
WEIGHT
COLOUR
ALLERGIES
PERTINENT/SUMMARY CASE INFORMATION *
VHS/Radiograph details if available:
Blood pressures (systolic/diastolic/mean):
Murmurs - grade, timing (systolic, diastolic, both, continuous) *
Arrhythmia - please describe:
Cough

Yes No
Syncope

Yes No
Exercise Intolerance

Yes No
Tachycardia

Yes No
Weight Loss

Yes No
Results from EKG/BP if available:
DIFFERENTIAL DIAGNOSIS *
i.e HCM, DCM, Mitral Valve disease, Endocarditis
PATIENT TEMPERAMENT

Calm Anxious/Stressed Hyper/Excited
Cardiac Ultrasounds: Patients should only be fasted if it is suspected they will require full sedation (fractious cats, very anxious or aggressive dogs).
INFORMATION FOR REFERRING VETERINARIANS
SEDATION PROTOCOLS

Light sedation such as butorphanol is often administered to keep patients calm and to provide pain relief during ultrasounds. Each patient will be assessed for their individual needs at the time of study. Fractious or highly stressed patients may receive further sedation to accommodate scanning and limit stress. Cardiac safe protocols are used such as midazolam/alfaxan for echos, only if patient requires. If you are declining sedation options as deemed necessary at the time of study, the study may not go forward or limited images may be taken.
Please advise if there are any contraindications to known sedation or previous reactions:

Yes No
Please provide further details:
Please advise client to give any oral anti-anxiety meds as directed prior to their visit.
- Added fee for blood pressure measurement
- Added fee for EKG
A cancellation fee of $50 will be billed to clients who do not provide notice within 24 hours.
I WOULD LIKE THE TEST RESULTS SENT TO ME VIA

Fax Email
DOCUMENTS
UPLOAD FILES HERE

i.e. bloodwork, medical history, etc.
Cancel of
Thank you for entrusting us with the care of your patient. We are happy to answer any questions you may have. A member of our team will reach out to you as soon as possible.
Should be Empty:

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

INFORMATION FOR REFERRING VETERINARIANS

DOCUMENTS