Consultation Request Form
Referring Veterinarian Information
REFERRING VETERINARY HOSPITAL NAME
REFERRING HOSPITAL 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.
PATIENT WEIGHT (KG)
PATIENT OWNER NAME
PATIENT OWNER PHONE NUMBER
Please enter a valid phone number.
PATIENT OWNER ADDRESS
Street Address Line 2
State / Province
Postal / Zip Code
PATIENT OWNER EMAIL
REASON FOR THE APPOINTMENT (SELECT ALL THAT APPLY)
Routine recheck evaluation
OFA evaluation (asymptomatic breeding animals only)
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 TIME PREFERENCE
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)
Client Consultation - virtual (the patient will be dropped off but I will also discuss results directly with the client by phone or videoconference at a later time - extra fee applies)
DO YOU HAVE ANOTHER PATIENT YOU WANTED TO SCHEDULE DURING THE SAME VISIT?
IF YES, PLEASE PROVIDE PATIENT NAME(S) BELOW:
Please complete a separate referral request for each patient - thank you!
OTHER IMPORTANT INFORMATION
Drag and drop files here
Choose a file
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.
Please verify that you are human
Name of The Form
Full Name of the Pet
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