Echocardiography Referral Form

Please complete this form at least 24 hours prior to the appointment and ensure you have notified the client of the following:

  • Patient should not be fed within 2 hours of the scheduled appointment but can have normal access to water
  • Patient will be shaved and may need to be sedated to obtain diagnostic images
  • Dogs should be given trazodone 2 hours prior to appointment unless their regular DVM deems it unsafe
  • Cats must be given gabapentin 2 hours prior to appointment unless their regular DVM deems it unsafe 
  • Client has been given an estimate of cost (please call for more information if needed)
  • Client will receive results via their regular DVM, typically within 24-48 hours of the appointment. Grand Valley Animal Clinic will not discuss ultrasound results with the client.

REFERRING HOSPITAL INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

Patient Should Be Seen (if possible) *
In addition to echocardiogram, please also perform:
Indications/Clinical Signs
Any recent changes in body condition?
Do you need comments on anesthesia for a procedure planned in the short-term future?

**Patient history must be provided prior to the appointment date**

 

Patient History may include:
1. Medical Records
2. X-rays
3. Lab Results
4. Other Documents

Security Question *