Consultation Request Form

REFERRING VETERINARY HOSPITAL NAME*

REFERRING VETERINARY HOSPITAL NAME

Where is your hospital located?*

Greater Victoria, Cobble Hill, Mill Bay, Duncan, Chemainus, Salt Spring IslandOther location

If your clinic is not in the list, please specify below:*

Value for type of appointment (Victoria)

Value for type of appointment (Other)

📅 Important Scheduling Notice – Please read before filling out the referral form

We have been receiving a high number of referrals from clinics located outside of Dr. Lichtenberger’s travel area. As a result, it has become increasingly challenging to accommodate all patients in a timely manner.

At this time, our waiting time is approximately 4 months.

While we occasionally arrange appointments in Duncan, these are scheduled on a case-by-case basis and depend on the availability of a clinic willing to accommodate outpatient visits and the patient’s history. Please do not advise clients that an appointment in Duncan will be possible. Victoria should be presented as the usual option for out-of-area patients.
Thank you for your understanding.

Please take a moment to read the information below and check the box to confirm that you have read it:

• Cardiology appointments are offered monthly for patients located outside our mobile coverage area at Island Veterinary Eye Specialist in Victoria.

• These appointments are for stable patients only. We will not have the ability to treat critical patients or hospitalize them.

• Please make sure to provide an estimate to the owners prior to sending a referral (see the fee schedule sent to the clinic).

• Mild sedation prior to the appointment can be helpful. Most cats benefit from gabapentin. The usual dose is 100 mg per cat, given 90 minutes before travel. If the cat is particularly agitated, 100 mg can also be given the evening prior to the visit. For dogs, at-home sedation can include trazodone (if no history of ventricular arrhythmias*; 5-8 mg/kg PO) and gabapentin (20 mg/kg PO) 90 minutes before travel. *Trazodone may increase the frequency of ventricular arrhythmias. Please avoid this drug in Dobermans with suspected DCM or Boxers with suspected ARVC.

• We will not have the ability to perform thoracic radiographs. If thoracic radiographs are indicated (most likely in the case of respiratory clinical signs), please perform them at your clinic. Dr. Lichtenberger will review them as part of his consultation.

• The referring veterinarian will need to prescribe and dispense ongoing medications. A complete report, including treatment recommendations, will be sent to you shortly after the appointment.

⚠️ Please fill out only one of the two fields above.

REFERRING HOSPITAL

REQUESTING VETERINARIAN*

First NameLast Name

REFERRING HOSPITAL EMAIL*

Confirmation EmailPlease use the best hospital email address for correspondence regarding scheduling and confirmation of the appointment.

Is this a recheck consultation with Dr Jonathan Lichtenberger? Please, select "No" if the patient previously had a consultation with another cardiologist or through a telemedicine service.*

YesNo

PATIENT NAME *

⚠️ Name cannot contain the '/' character. Please use a hyphen (-) instead.

PATIENT WEIGHT (KG)*

PATIENT BIRTHDATE*

GENDER*

SPECIES*

CanineFelineOther

BREED*

COLOUR*

PATIENT OWNER NAME*

First Name

Last Name

PATIENT OWNER NAME

⚠️ First and last names cannot contain the '/' character. Please use a hyphen (-) instead.

PATIENT OWNER PHONE NUMBER*

Please enter a valid phone number.

PATIENT OWNER ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

PATIENT OWNER EMAIL

example@example.com

🔔 Please make sure to include a valid email address for the owner, as this is how we will contact them to schedule the appointment.

REASON FOR THE APPOINTMENT (SELECT ALL THAT APPLY)*

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)

TYPE OF APPOINTMENT REQUESTED*

Mobile Services - Drop-off (Dr. Lichtenberger will not meet with the clients - results of the evaluation will be communicated to requesting DVM for discussion with client)Mobile Services - Client Consultation - in person (Dr. Lichtenberger will also discuss results directly with the client following evaluation - extra fee applies)Outside Mobile Service Area – The consultation will take place at ISLAND VETERINARY EYE SPECIALIST (stable patients only)

TYPE OF APPOINTMENT REQUESTED*

Drop-off (Dr. Lichtenberger will not meet with the clients - results of the evaluation will be communicated to requesting DVM for discussion with client)Client Consultation - in person (Dr. Lichtenberger will also discuss results directly with the client following evaluation - extra fee applies)

TYPE OF APPOINTMENT REQUESTED*

Outpatient

Value type of appointment MS

Value type of appointment Outpatient

Do you have another patient you would like to schedule during the same visit, or would you like to add this patient to an existing appointment?*

YesNo

IF YES, PLEASE PROVIDE PATIENT NAME(S) BELOW:

Please complete a separate referral request for each patient - thank you!

OTHER IMPORTANT INFORMATION

RECORD UPLOAD

Please upload recent medical records and pertinent files here, including thoracic radiographs (images and report if available), lab work, previous non-PCVC cardiology reports. This method is preferred. If sending them separately, please email them within 24 hours.

Please ensure that all radiographs are properly identified with the patient’s name, the client’s name, and the date the images were taken, as required by the CVBC.

Record Uploaded

Name of The Form

Full Name of the Pet

Space

Send a reminder

YesNo

Where the consultation will take place*

Recheck Consultation

Type of Appointment

🔔 Important: It looks like no medical records — including thoracic radiographs (images and report if available), lab work, or previous non-PCVC cardiology reports — have been attached. If you would like to send them by email, please do so as soon as possible so we can proceed with the referral.

Please verify that you are human*

Consultation Request Form

Referring Veterinarian Information

📅 Important Scheduling Notice – Please read before filling out the referral form

Please take a moment to read the information below and check the box to confirm that you have read it:

Patient Information

⚠️ Name cannot contain the '/' character. Please use a hyphen (-) instead.

⚠️ First and last names cannot contain the '/' character. Please use a hyphen (-) instead.

Appointment Details

RECORD UPLOAD

⚠️ First and last names cannot contain the '/' character.