Patient Name(Required) First Human Companion(Required) First Last Client Email(Required) Client Phone(Required)Species(Required)Breed(Required)Age (ideally date of birth)(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 Referring Veterinary Hospital(Required)Requesting Veterinarian(Required)Hospital Email address(Required) Veterinarian Email address Hospital phone number(Required)Veterinarian phone numberWhich location would you like to refer to?(Required) BrightCare Veterinary Group – Mission Viejo, CA 92692 Animal Emergency and Urgent Care – Bakersfield, CA 93309 Bakersfield Veterinary Hospital – Bakersfield, CA 93311 CASE Animal Hospital – Anaheim, California 92806 PETS Hospital – Orcutt, CA 93455 Coast to Coast Cardiology – Santa Barbara, CA 93105 VCA Lakewood Animal Hospital – Cerritos, CA 90703 Pacific Care Pet Emergency + Specialty – Irvine, CA 92614 Coast to Coast Cardiology – Newton, MA 02464 Coast to Coast Cardiology – Peabody, MA 01960 Veterinary Specialty Center of Sturbridge – Sturbridge, MA 01566 OtherCardiologyFull 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 NoAppointment 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 NoImaging 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.Patient Scheduling(Required) I have instructed the client to contact you for scheduling at 844-582-3827, via email, or online, OR I would prefer Coast to Coast Veterinary Specialists call/email the client to set up an appointmentPatient Name(Required)Current Working Diagnosis(Required)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.com(Required)Please upload the medical records. Alternatively, please email them to info@CCCvetService.com Drop files here or Select filesMax. file size: 128 MB.Records Request(Required) I have uploaded all pertinent records, labs, and radiographs above I have emailed all pertinent records, labs, and radiographs to you at info@CCCvetService.com, OR I have faxed all pertinent records, labs, and radiographs to you at 844-582-3828Δ
