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.*

DyspneaExtreme LethargyCollapseObtunded/comatose103.5 or greater body temperaturePulse DeficitsClinical arrhythmiaNone of the above
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

CoughingExercise intoleranceDyspnea (difficulty breathing)Tachypnea (rapid breathing)Syncope (collapse/fainting)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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