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Echocardiogram Referral
Echocardiograms are typically performed on select Tuesdays. If this is an emergency, please call us at 505-471-4400. All information below is submitted along with the echo exam to a board-certified cardiologist, with their report sent directly to the referring DVM. Please fill out the form completely and include most recent thoracic radiographs (these are needed prior to echo appointment).
Date of Referral
*
Date Format: MM slash DD slash YYYY
Level of urgency
High Priority
First Available
Routine follow up
Referring DVM
*
Referring Practice
*
Phone
*
Email
*
Client Information
Name
*
First
Last
Phone
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Email
*
Patient Information
Patient Name
*
First
Species
*
Canine
Feline
Breed
*
Weight (lbs)
*
Date of Birth
*
Date Format: MM slash DD slash YYYY
Sex
*
Intact Male
Neutered Male
Intact Female
Spayed Female
Current Rabies Vaccine
Yes
No
Cardiac Details
Date of last thoracic radiographs (please attach below)
Date Format: MM slash DD slash YYYY
Previous echo to compare? (If yes please attach below):
*
Yes
No
If yes, Date:
Date Format: MM slash DD slash YYYY
Reason for echocardiogram (select all that apply)
*
Heart Murmur
Abnormal Breathing
Coughing
Arrhythmia or ECG abnormality
Exercise Intolerance
Syncope/collapse
Acute onset paralysis
History of grain free or other atypical diet
Pre-chemotherapy study
Heartworm positive status
Is the problem:
*
New
Chronic
History/Chief Complaint
Patient's Appetite
Increased
Decreased
Stable
Mucous membranes:
Normal
Abnormal
Pulse Quality:
Heart Murmur:
*
Yes
No
Murmur Grade (1-6):
*
Point of maximal intensity:
left apical
right apical
left basilar
right basilar
left parasternal
right parasternal
heard loudly in all parts of the chest
Timing:
Systolic
Diastolic
Continuous
Cardiac Rhythm:
Regular
Irregular
Best describes Pet's attitude/demeanor:
Bright
Quiet
Dull/depressed/lethargic
Obtunded
Comatose
Anxious
Aggressive
Body condition score (1-9):
Changes in Body Condition:
Stable
Recent weight gain
Recent weight loss
Recent muscle wasting
Additional relevant physical findings
Completed diagnostics (please attach below):
Any relevant prior treatments patient received for the current clinical signs:
Current cardiac medications (name, dose, route, frequency):
*
Please describe the patient's response to these cardiac medications, if any:
Any other medications or supplements:
*
File
File
File
File
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About Us
Our Doctors
Our Team
Our App
Careers
Services
New Clients/New Pets
New Client Registration Form
New Pet Registration Form
Referrals
Referrals- Surgery/Endoscopy/General
Referrals- Echocardiogram
Contact Us
Resources
International Travel
Emergency
Online Store
Prescription Refill
facebook
