Comprehensive Cardiology Consult Referral Form

Save time during your next appointment! Complete your required comprehensive cardiology consult referral form
online from any device at any time before your visit.

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Comprehensive Cardiology Consult Referral Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Thanks for trusting and referring your patient to Oncura Partners Veterinary Imaging Center. Once we have performed the ultrasound procedure you will receive the results report back to the email on file. If you have any questions, do not hesitate to contact us.

We suggest that an oral sedative be prescribed but this is not mandatory. If you and the family believe this is not necessary we can do without. For suggested protocol please refer to our Referring Vets dropdown. Please indicate whether an oral sedative will be prescribed. *

Yes
No

Are there any matters concerning the client or the pet that we should be made aware of (will be kept confidential):

The internal medicine specialists who will be completing the consultation will require updated bloodwork and radiographs. Will this information be provided prior to the procedure? *

Yes
No

Please upload medical records, labs, images, and previous referral reports

Click or drag files to this area to upload. You can upload up to 15 files.

Client Name *

First

Last

Email *

Client Phone *

Patient Name *

Patient Weight *

Patient Age *

Referring Veterinarian Hospital *

Referring Veterinarian *

Referring Veterinarian Email *

Email or Fax number where you’d like results sent (if different from above)

Reason for the Exam. Please include clinical signs, duration, and any other information that will assist the cardiologist in providing the most accurate report *

Are there any concurrent illnesses? *

Differential List

List medications and supplements including dosage and frequency that patient is currently on

List any medications that the patient has been on for this problem that have been discontinued

Other comments to share with us that may assist our cardiologist provide the most accurate and useful report for you?

Comprehensive Cardiology Consult Referral Form

Comprehensive Cardiology Consult Referral Form

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