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Cardiology Referral Form
Today’s date:
Patient Name:
Weight:
Age:
Breed:
Client Name
Client Email
Client Address
Address
Address 2
City/Town
State/Province
- None -
Alabama
Alaska
American Samoa
Arizona
Arkansas
Armed Forces (Canada, Europe, Africa, or Middle East)
Armed Forces Americas
Armed Forces Pacific
California
Colorado
Connecticut
Delaware
District of Columbia
Federate States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP/Postal Code
Client Phone:
Date of Rabies Vaccination
Please send last 12 months records including radiographs and current blood work.
Rabies vaccine type:
1 year
3 year
Referring Vet Name and Hospital Name:
Referring Hospital Phone number:
Referring Hospital Email address:
Reason for Referral (To be filled out by referring vet):
New Heart Murmur
Heart Murmur Worsening in Intensity
Arrhythmia
Collapse/Syncope
Cough
It’s complicated (Please describe):
Enter other…
Current Medications (please include flea/tick/heartworm preventatives):
Do you require anesthesia recommendations for this patient?
Yes
No
Will the patient require sedation due to temperament? If yes, please consider prescribing gabapentin and/or trazodone to give prior to the appointment.
Yes
No
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