Cardiology Consultation Inquiry

Please complete all required fields.

Today's date Today's date / MM / DD YYYY
Veterinarian's name Veterinarian's name First Last
Practice name
Practice zip code
Practice phone number Practice phone number - ### - ### ####
Contact email
Which is the best contact method for providing consultation results?

Which is the best contact method for providing consultation results? Email Phone
Goal of consult/what questions would you like answered?
Client name Client name First Last
Patient information
Patient name Patient name First Last
Breed
Gender

Gender Male Female
Date of birth or age
Date of most recent patient evaluation Date of most recent patient evaluation / MM / DD YYYY
Exam TPR
Patient weight (kg)
Is a heart murmur present?

Is a heart murmur present? Yes No
Please describe including grade, location, timing and date when first documented.
Is an arrhythmia present?

Is an arrhythmia present? Yes No
Please describe (fast, slow, regular, irregular, premature beats, long pauses, etc), including date first documented and ECG image, if available.
Please upload copy of most recent ECG

Attach Files
Has a blood pressure been performed?

Has a blood pressure been performed? Yes No
Please provide blood pressure results, including method of acquisition (Doppler, oscillometric).
Have thoracic radiographs been performed?

Have thoracic radiographs been performed? Yes No
Please provide results of thoracic radiographs.
Please upload thoracic radiographs

Attach Files
Has bloodwork been performed?

Has bloodwork been performed? Yes No
Please upload bloodwork results here.

Attach Files
What medications is the patient currently receiving? Please list all, including non-cardiac medications. Provide in the following format: furosemide 20 mg tablets: ½ tablet (10 mg) by mouth every 12 hours.
Please provide a summary of the patient’s medical history and comorbid diseases, if applicable, and attach the patient's complete medical record below.
Patient medical record.

Attach Files
Please provide the preventative history (flea/heartworm/tick).
Please provide the patient’s current diet.

Cardiology Consultation Inquiry

Cardiology Consultation Inquiry

Patient information