Consultation Request Form

Consultation Request Form
Referring Veterinarian Information
REFERRING VETERINARY HOSPITAL NAME*
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 Information
PATIENT NAME *
PATIENT WEIGHT (KG)*
PATIENT BIRTHDATE*

MonthDayYear
GENDER*
SPECIES*

CanineFelineOther
BREED*
COLOUR*
PATIENT OWNER NAME*
First Name
Last Name
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
REASON FOR THE APPOINTMENT (SELECT ALL THAT APPLY)*

Heart murmurArrhythmiaSyncope/weakness/collapseExercise intoleranceCoughingTachypnea/dyspneaPre-anesthetic evaluationRoutine recheck evaluationOFA 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
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)
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.
Cancelof
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.
Name of The Form
Full Name of the Pet
Space
Full Name of the Owner
Send a reminder

YesNo
Where the consultation will take place*
Recheck Consultation
Type of Appointment
Please verify that you are human*
Should be Empty:

Consultation Request Form

Referring Veterinarian Information

Patient Information

Appointment Details

RECORD UPLOAD

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