ECHO Submission Form
Referring Clinic
*
Referring Clinic Phone Number
*
Please enter a valid phone number.
Referring DVM
*
Referring DVM Email
*
example@example.com
Date of Echo
*
-
Month
-
Day
Year
Date
Time of Echo
*
Hour Minutes
AM
PM
AM/PM Option
Owner approval for multi lead EKG-after staff approval
*
Clinic acknowledges that if information is not submitted prior to echo, it will not be included in history to the cardiologist
Patient Name
*
Patient Species
*
Please Select
Canine
Feline
Breed
*
Age
*
Sex
*
Please Select
Female
Spayed Female
Male
Neutered Male
Weight (in pounds)
*
Heart Rate
Blood Pressure
Heart Murmur
*
Yes
No
If yes, please explain (ie. grade, date noticed, intensity changes)
Collapse / Syncope
*
Yes
No
If yes, please explain
Cough
*
Yes
No
If yes, please explain
Arrhythmia
*
Yes
No
If yes, please explain
Elevated Pro BNP
*
Yes
No
If yes, include Pro BNP number
Does this patient need anesthesia clearance?
*
Yes
No
Is this a recheck?
*
Yes
No
If yes, was it with Mobile Pet Imaging?
*
Yes
No
Please list current medications your pet is taking.
*
EXAMPLE: 1. Pimobendan 2.5 mg BID .....
Please attach the following if applicable (check all that you are attaching)
*
Radiographs
Medical Report
Lab Results
Other information that is important for this echo
Patient Records
*
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