Patient Name(Required) First Last Human Companion(Required) First Last Client Email (if available) Client Phone (if available)Referring Veterinary Hospital(Required)Hospital phone number(Required)Hospital City and State(Required)Requesting Veterinarian(Required)Services Available at Coast To Coast CardiologyCARDIOLOGY Full cardiac evaluation and diagnostic workup, including but not limited to echocardiography, ECG/EKG, blood pressure assessment, Holter monitor placement, radiography, pre-anesthetic recommendations. 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) are offered at our fluoroscopic interventional laboratory and surgical suite, located at our Newton Hospital.INTERNAL MEDICINE (ONLY AVAILABLE 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. Case management remains with the referring veterinarian.What service(s) do you need?(Required)Please select a serviceCardiologyInternal Medicine (ONLY Available in Peabody, MA)Cardiology AND Internal MedicineCardiologySpeciesBreedAge (ideally date of birth)Current Working Diagnosis(Required)Appointment Preparation: Please encourage owners to administer pre-visit sedation (i.e. gabapentin, trazodone) if the patient has a significant Fear, Anxiety, Stress (FAS) score. Access to water and food does not necessarily need to be restricted unless significant sedation is anticipated.Internal MedicineSpeciesBreedAge (ideally date of birth)Current Working Diagnosis(Required)Appointment 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.Please upload the relevant medical records for cardiology and internal medicine. Alternatively, please email them to info@CCCvetService.com Drop files here or Select filesMax. file size: 128 MB.Δ
