Consultation Request Form
Referring Veterinarian Information
REFERRING VETERINARY HOSPITAL NAME
*
REQUESTING VETERINARIAN
*
First Name
Last Name
REFERRING HOSPITAL EMAIL
*
Confirmation Email
Please use the best hospital email address for correspondence regarding scheduling and confirmation of the appointment.
Is this a recheck consultation for Dr Jonathan Lichtenberger? Please, select "No" if the patient previously had a consultation with another cardiologist or a telemedicine service.
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Yes
No
Patient Information
PATIENT NAME
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PATIENT WEIGHT (KG)
*
PATIENT BIRTHDATE
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Month
-
Day
Year
GENDER
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Please Select
Female (intact)
Female (spayed)
Male (intact)
Male (castrated)
SPECIES
*
Canine
Feline
Other
BREED
*
COLOUR
*
PATIENT OWNER NAME
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First Name
*
Last Name
PATIENT OWNER PHONE NUMBER
*
Please enter a valid phone number.
PATIENT OWNER ADDRESS
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PATIENT OWNER EMAIL
example@example.com
REASON FOR THE APPOINTMENT (SELECT ALL THAT APPLY)
*
Heart murmur
Arrhythmia
Syncope/weakness/collapse
Exercise intolerance
Coughing
Tachypnea/dyspnea
Pre-anesthetic evaluation
Routine recheck evaluation
OFA evaluation (asymptomatic breeding animals only)
Other
PATIENT IDENTIFICATION
*
This is required for OFA evaluations.
PLEASE PROVIDE A BRIEF PERTINENT HISTORY
*
PLEASE PROVIDE A BRIEF PERTINENT HISTORY (any changes since last cardiac evaluation?)
*
CURRENT MEDICATIONS (including formulation, dose and frequency)
*
CURRENT DIET (if known)
Appointment Details
APPOINTMENT TIME PREFERENCE
*
Anytime
Morning (8:30 am - 12:30 pm)
Afternoon (1pm - 4 pm)
TYPE OF APPOINTMENT REQUESTED
*
Drop-off (I will not meet with the clients - results of the evaluation will be communicated to requesting DVM for discussion with client)
Client Consultation - in person (I will also discuss results directly with the client following evaluation - extra fee applies)
DO YOU HAVE ANOTHER PATIENT YOU WANTED TO SCHEDULE DURING THE SAME VISIT?
*
Yes
No
IF YES, PLEASE PROVIDE PATIENT NAME(S) BELOW:
Please complete a separate referral request for each patient - thank you!
OTHER IMPORTANT INFORMATION
RECORD UPLOAD
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Please upload recent medical record and pertinent files (thoracic radiographs, labwork, previous non-PCVC cardiology reports). Having recent medical records ensures a smooth referral process so all patient information is available prior to the appointment.
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Please verify that you are human
*
Name of The Form
Full Name of the Pet
Send a reminder
Yes
No
Where the consultation will take place
*
Recheck Consultation
Type of Appointment
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