Cardiology - Veterinarian Referral

Cardiology - Veterinarian Referral

This referral form is exclusively for those patients being referred directly by a veterinarian overseeing their care. IF YOU ARE AN OWNER, this is the incorrect form please fill out the owner referral form. Referral for patients to be seen at our Outpatient Imaging Center.
Patient Name
Pet Name Only
Species
Sex
Breed
Age
Owner Name
First Last
Owner Phone Number
Owner Email Address
Owner Address
Street, City, Zip
Referring Veterinary Clinic
Referring Veterinarian
Referring Veterinary Phone Number
Referring Veterinary Email Address
Phone contact for referring veterinarian in case of urgent need
(if different from above)
Is the patient exhibiting any of the following clinical signs? Please explain below. The patient needs to be stable for an outpatient ultrasound. If the patient is not stable, ER referral is recommended.
If any of the above checked, please explain severity and agree that your patient is stable for an outpatient cardiology.
Urgency of appointment
Reason for referral
Current medications & OTC supplements (please include drug, dose, route, & frequency)
Clinical signs of heart disease

Other
Known co-morbidities
We will send the final report to you with 48 hours of the consultation. If clinical judgement deems urgent, a member of the SSVI team will attempt to contact you at the number provided above.
Please upload any pertinent files. Please only include records relating to the indication for the study.

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