Outpatient Echocardiogram Request

Echocardiograms are currently limited to patients:

-Under 50lbs

-Over 1 year old

-No known congenital heart defects

Please call us at (352) 225-3501 if you have any questions while filling out this form

Requesting DVM Name:

DVM Phone number:

DVM Email address:

(You will also receive a copy of this request.)

Name of Pet Owner:

Owner's Cell Phone Number:

Owner's Email Address:

Name of Pet:

Species:

Breed:

Age of Pet:

Is Pet a Male or Female?

Has this pet been spayed or neutered?

Study Requested:

Echocardiogram

Is this Echocardiogram URGENT? (If yes, an emergency consult fee may be added if the patient requires immediate medical intervention.)

Yes

Clinical History:

Concurrent diseases/comorbidities:

Specific concern for the current study and questions to be answered by the Radiologist:

Please list current Cardiac Medications:

Please list any other current medications:

Heart murmur description:

Has this patient had a diagnostic ECG?

Clear choice

YES

We recommended that the referring veterinarian prescribe anxiolytic medications to be given the night before and morning of the appointment. (Gabapentin, Trazodone and Acepromazine are currently approved for use during echocardiograms; feel free to contact us via phone or email prior to the echocardiogram appointment.)

Anxiolytic medications prescribed:

Please upload patient's records here

If records are not attached, please email to reception@ccvetspecialists.com

Delete all uploads

Choose files or drag here

Patient preparation:

Patient must have had a physical exam by a veterinarian within the past 30 days

All patients should be fasted after midnight the night prior to the exam

(water is allowed, give routine medication as prescribed).

Sedation may be necessary to perform the study. Please list any known medication reactions or contraindications (heart disease, kidney injury):

Communication of imaging findings:

Please note - this is an outpatient procedure. Any echocardiography report will be emailed to the referring veterinarian by a board certified cardiologist within 72 business hours. It is the responsibility of the referring veterinarian to relay results to the owner.

Email report only

Phone call from the radiologist and email report