Cardiology Service Request
Please complete this form to request an appointment with our Cardiology Team
Referring Practice/Clinic
*
Attending Clinician
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
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Owner's Details
*
First Name
Last Name
Owner's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Owner's Email
*
example@example.com
Owner's Phone Number (Main)
*
-
Area Code
Phone Number
Owner's Mobile Number
*
-
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PATIENT'S DETAILS
Patient's Name
*
Species
*
dog
cat
Sex
*
FE
FN
ME
MN
Breed
*
Date of Birth
*
-
Day
-
Month
Year
Date
Body Weight (Kg)
*
Reasons for Cardiology Referral
*
Current cardiac medications?
Patient's History
*
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Exam Requested
Tests Requested
*
Categories:
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( X )
Colour Doppler Echocardiography
£
649.20
Quantity
1
2
3
4
5
6
7
8
9
10
6-lead ECG
5-minute continuous recording
£
221.64
Quantity
1
2
3
4
5
6
7
8
9
10
Blood Pressure
Doppler Blood Pressure Measurement
£
110.04
Holter monitoring
24h; 48h; 72h recording available. Estimate refers to 24h recording, including return special delivery shipping
£
490.80
Puppy/Kitten Heart Murmur
Investigation of a heart murmur in an asymptomatic puppy/kitten younger than 6 months
£
195.00
Quantity
1
2
3
4
5
6
7
8
9
10
Terms & Conditions
*
I understand that this is an outpatient service only, and that there will be no consultation with my client. All diagnostic reports and clinical recommendations will be forwarded to me directly to be discussed with my client. I accept that, as the referring clinician, I will retain case responsibility and that this patient will remain under my care for clinical management. I understand that the referred patient must be clinically stable and fit to travel on the day of the appointment. In the unlikely event of sedation being required, this will be charged additionally.
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