Referring Clinic and Veterinarian

Clinic *

Referring Veterinarian *

Telephone *

Direct contact number for questions or urgent findings *

Email For Report *

Alternate veterinarian/contact if referring veterinarian is unavailable *

I confirm that our clinic will review the report, communicate the results to the client and arrange ongoing care.

I agree and understand

Client and Patient Information

Owner’s Name *

First

Last

Telephone *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Patient’s Name *

Species *

Canine
Feline

Breed *

Age/Date of Birth *

Sex/Neuter Status *

Most Recent Weight and Date *

Clinical Referral

Urgency *

Emergency - 36h
Urgent - 2d to 5d
Routine - 2 weeks

Reason For Echocardiography / Clinical Question *

Please include the specific clinical question(s) you would like the echocardiogram to address

Address Line 1

Address Line 2

City

State

Zip Code

Relevant History *

Include duration of signs, progression, previous treatment and response.

Relevant Abnormal Examination Findings

Heart Rate *

Rhythm *

Regular
Irregular

Murmur *

No
Yes

If Yes *

Grade / VI *

Location / Point of Maximal Intensity *

Timing *

Systolic
Diastolic
Continuous
Unsure

Pulse Quality / Abnormalities *

Respiratory Rate *

Respiratory Effort *

Normal
Increased

Current or Recent Cough *

No
Yes

History of Weakness/Collapse/Syncope *

No
Yes

Current Oxygen Requirement or Respiratory Distress *

No
Yes

If yes, please provide details and contact EVC directly when referring

Birth and or

Previous Cardiac or Relevant Diagnostics

Please attach all relevant and current medical records. These are required for appropriate interpretation of the cardiology recommendations and for safe prescribing if medications are initiated at EVC.

Thoracic Radiographs

Date

Relevant Findings

Date/Findings (ECG) *

Date/Result (Blood Pressure)

Date/Result (NT-proBNP)

Date/Result (Cardiac Troponin)

Date/Report Attached (Previous Echocardiogram)

Drag & Drop Files, Choose Files to Upload

Other Relevant Laboratory or Imaging Results

Drag & Drop Files, Choose Files to Upload

Known Cardiac Disease

Previous Cardiac Diagnosis, If Applicable

Date Diagnosed

Previous Echocardiogram Findings

Previous Cardiology Consultation

Current Medications and Supplements

Please provide all current medications, including dose, frequency, and when the medication was last administered. This is particularly important for cardiac medications, diuretics, ACE inhibitors, spironolactone, antihypertensives, and any medications that may affect heart rate or blood pressure.

Medication *

Dose *

Frequency *

Last Dose *

Additional Medications *

Please include any prescribed pre-visit medication.

Relevant Concurrent Disease

Please indicate any conditions that may affect cardiac assessment or patient handling, including:

Renal Disease *

Endocrine Disease *

Respiratory Disease *

Systemic Hypertension *

Anemia *

Other Significant Conditions *

FAS and Handling Requirements

Include fear, anxiety, stress, bite history, handling triggers and successful handling strategies. Patients with FAS equal or above 2 must be dispensed PVPs for the night before and the morning of the procedure to avoid stress and to obtain the best image quality. Oral PVP’s will not affect echocardiogram results. Please follow the recommended dosing guidelines below:

Cats: Gabapentin 10-20 mg/kg OR 50-100 mg per cat, the night before and 60-90 minutes prior to the appointment. In some cases dose can be increased (ex: patients known to be fractious or extra anxious). Potentially 40 mg/kg OR up to 240-300mg per cat.

Dogs: Trazodone 3-5 mg/kg & Gabapentin 10 mg/kg the night before and 2 hours prior to apt.

I have informed the client and dispensed the appropriate medication(s) *

I have read and agree

Known Allergies or Previous Medication/Sedation Reactions

Sedation

Echocardiography is generally performed without sedation whenever possible.

If sedation is necessary for patient safety or to obtain diagnostic-quality images, the EVC veterinarian will determine whether sedation is appropriate and select the protocol based on the patient’s cardiac status and medical history. *

Owner has been advised that sedation may occasionally be required
Known previous sedation/anesthetic concerns

Referring Veterinarian Confirms: *

Complete and current medical records have been provided.
Current medications, doses, and frequency have been provided.
I understand that an EVC veterinarian will review the cardiologist’s findings and recommendations with the client.
I understand that EVC may dispense or prescribe initial medications when clinically appropriate based on the cardiologist’s recommendations.
I understand that the echocardiography report, recommendations, and details of any medications initiated at EVC will be forwarded to our clinic for ongoing management and follow-up.

Name of Person Providing Consent *

Date of Discussion *

EVC will confirm its estimate and obtain procedure consent before proceeding *

I agree and understand

Request An Appointment

Emergency

Echocardiogram Referral Form