Patient Name(Required) First Last Human Companion(Required) First Last Client Email(Required) Client Phone(Required)Referring Veterinary Hospital(Required)Hospital Email address(Required) Hospital phone number(Required)Requesting Veterinarian(Required)Veterinarian Email address Veterinarian phone numberRequesting Veterinarian City and State(Required)CardiologyFull cardiac evaluation and diagnostic workup, including but not limited to echocardiography, ECG/EKG, blood pressure assessment, Holter monitor placement, radiography, pre-anesthetic recommendations, OFA Certification, agitated saline studies, and atropine response tests. Consultation with the client directly with formulation of a treatment plan, follow-up recommendations, and long-term monitoring and management of chronic cardiac disease. Minimally invasive procedures (including but not limited to balloon valvuloplasty, pacemaker implantation, and PDA occlusion) offered at our Newton MA office.Do you need a Veterinary Cardiologist?(Required) Yes NoSpeciesBreedAge (ideally date of birth)ColorGender Female spayed Female intact Male neutered Male intactWeight (Indicate kg or lbs)Date of Request MM slash DD slash YYYY Current Working DiagnosisAppointment Preparation: Please encourage owners to administer pre-visit sedation (i.e. gabapentin, trazodone) if the patient has a significant FAS score. Access to water and food does not necessarily need to be restricted unless significant sedation is anticipated.Internal Medicine (ONLY in Peabody, MA)Diagnostic ultrasounds (abdominal, cervical, non-cardiac thoracic), fine needle aspiration and cystocentesis with return of diagnostic test results and samples to the referring veterinarian for review with the client. Patient care and case management with the primary care veterinarian.Do you need a Board Certified Veterinary Internist? (performed ONLY at our Peabody office located at 2 First Avenue, Peabody, MA)(Required) Yes NoSpecies(Required)Breed(Required)Age (ideally date of birth)(Required)Color(Required)Gender(Required) Female spayed Female intact Male neutered Male intactWeight (Indicate kg or lbs)(Required)Date of Request(Required) MM slash DD slash YYYY Current Working Diagnosis(Required)Imaging Region Requested(Required) Abdomen Thorax (non-cardiac) Cervical (sedation required) OtherPlease specify(Required)Ultrasound-guided Aspirates and Thoracocentesis/Abdominocentesis: Please discuss the possibility of aspirates or -centesis and potential need for sedation with client prior to appointment(Required) Aspirates will be offered if indicated based on case findings and any noted lesions Owner has expressed a wish for imaging without aspirates at this timePlease also note if you would like aspirates of a particular area if indicated(Required)Cystocentesis(Required) Yes Only if indicated based on other findings NoAppointment Preparation:Please instruct owners to withhold food for 12 hours prior to the examination unless medically contraindicated.Access to water should not be restricted unless significant sedation is anticipated.While oral pre-visit sedation is not a requirement, it is strongly encouraged for all patients. Please obtain consent for sedation and fine needle aspirates (if needed) in advance. A CBC is required to be performed within 1 month if aspirates are requested.Reason for Visit (include brief history and pertinent physical exam findings)(Required)Recent Diagnostic Findings: **UPLOAD below or EMAIL all lab work, radiographs, and records to info@CCCvetService.comPlease upload the relevant medical records for cardiology. Alternatively, please email them to info@CCCvetService.com Drop files here or Select filesMax. file size: 128 MB.Please upload the relevant medical records for internal medicine. Alternatively, please email them to info@CCCvetService.com Drop files here or Select filesMax. file size: 128 MB.Δ
