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

Date

REFERRING HOSPITAL

rDVM NAME

PHONE NUMBER

FAX NUMBER

EMAIL

example@example.com

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

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).

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

UPLOAD FILES HERE

function SvgDhtupload(props) { return /* @__PURE__ */ react.createElement("svg", dhtupload_svg_extends({ width: 54, height: 47, xmlns: "http://www.w3.org/2000/svg" }, props), dhtupload_svg_path || (dhtupload_svg_path = /* @__PURE__ */ react.createElement("path", { d: "M40.213 10.172c1.897.21 3.68.738 5.35 1.58a15.748 15.748 0 014.374 3.242 15.065 15.065 0 012.951 4.533c.72 1.704 1.08 3.522 1.08 5.455 0 1.827-.28 3.654-.843 5.48-.562 1.828-1.379 3.47-2.45 4.929A13.39 13.39 0 0146.669 39c-1.599.948-3.452 1.458-5.56 1.528H37.26a1.62 1.62 0 01-1.185-.5 1.62 1.62 0 01-.501-1.186c0-.457.167-.852.5-1.186.334-.334.73-.5 1.186-.5h3.848c1.44 0 2.75-.37 3.926-1.108a10.851 10.851 0 003.03-2.846 13.53 13.53 0 001.95-3.9 14.23 14.23 0 00.686-4.321c0-1.582-.316-3.066-.949-4.454a11.623 11.623 0 00-2.582-3.636 12.857 12.857 0 00-3.742-2.478 11.054 11.054 0 00-4.48-.922l-1.212-.053-.37-1.159c-.878-2.81-2.292-4.998-4.242-6.562-1.95-1.563-4.594-2.345-7.932-2.345-2.108 0-4.005.36-5.692 1.08-1.686.72-3.136 1.722-4.348 3.005-1.212 1.282-2.143 2.81-2.793 4.585-.65 1.774-.975 3.68-.975 5.718h.053l.105 1.581-1.528.264c-1.863.316-3.444 1.317-4.744 3.004-1.3 1.686-1.95 3.584-1.95 5.692 0 2.39.8 4.462 2.398 6.219 1.599 1.757 3.488 2.635 5.666 2.635h4.849c.492 0 .896.167 1.212.5.316.335.474.73.474 1.187 0 .456-.158.852-.474 1.185-.316.334-.72.501-1.212.501h-4.849a10.08 10.08 0 01-4.374-.975 11.673 11.673 0 01-3.61-2.661 13.173 13.173 0 01-2.478-3.9A12.073 12.073 0 010 28.301c0-2.706.755-5.148 2.266-7.326 1.511-2.178 3.444-3.636 5.798-4.374.14-2.354.658-4.542 1.554-6.562.896-2.02 2.091-3.777 3.584-5.27 1.494-1.494 3.25-2.662 5.27-3.505C20.493.422 22.733 0 25.193 0c1.898 0 3.637.237 5.218.711 1.581.475 3.004 1.151 4.269 2.03a13.518 13.518 0 013.268 3.215 18.628 18.628 0 012.266 4.216zm-11.964 13.44l6.22 6.85c.245.247.368.537.368.87 0 .334-.123.642-.369.923l-.421.263c-.211.246-.484.343-.817.29a1.544 1.544 0 01-.87-.448l-3.69-4.11v16.97c0 .492-.166.896-.5 1.212-.334.316-.729.474-1.186.474-.492 0-.896-.158-1.212-.474-.316-.316-.474-.72-.474-1.212V28.25l-3.584 4.005a1.544 1.544 0 01-.87.448.959.959 0 01-.87-.29l-.42-.264c-.247-.28-.37-.588-.37-.922 0-.334.123-.624.37-.87l6.113-6.746v-.052l.421-.422a.804.804 0 01.396-.29c.158-.053.307-.079.448-.079.175 0 .333.026.474.079.14.053.281.15.422.29l.421.422v.052z", fill: "none" }))); }

i.e. bloodwork, medical history, etc.

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.

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

INFORMATION FOR REFERRING VETERINARIANS

DOCUMENTS