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Contact Us
Maryland
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Kentucky
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Member Login
About Us
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Our Cardiologists
Kentucky
Maryland
Texas
Virginia
Dog Heart Disease
Cat Heart Disease
Pet Owners
COVID-19
*New Patient Registration Form
*What to Expect: Initial Consultation
*Why CVCA
Why Choose a Board-Certified Veterinary Cardiologist?
10 Signs of Heart Disease
Clinical Studies
Diagnostics
Drug Handouts
FAQ for Clients
Facebook/Instagram Submission Form
Payment Options
Pet Nutrition Resources (Grain-Free)
Pimobendan/Vetmedin Shortage
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Veterinarians
*Refer a Patient Form
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Consult – Internal Request
Select a State:
*
Choose a state
Maryland
Virginia
Kentucky
Texas
You must select a location below to ensure CVCA receives this form.
Maryland
*
Please select the office you are referring to:
Annapolis, MD
Columbia, MD
Frederick, MD
Gaithersburg, MD
Rockville, MD
Towson, MD
Virginia
*
Please select the office you are referring to:
Fairfax, VA
Leesburg, VA
Richmond, VA
Springfield, VA
Vienna, VA
Kentucky
*
Please select the office you are referring to:
Louisville, KY
Texas
*
Please select the office you are referring to:
NW Austin, TX
Shoal Creek - Austin, TX
Owner Name (First and Last)
*
First
Last
Previous Name Field (Ignore)
Best # for Client
*
Previous # Field (Ignore)
Address
*
Street Address
City
State
Zip
Home Phone
*
Work Phone
Email
*
Current CVCA Client:
*
Yes
No
Patient Name
*
Species
*
K9
Feline
Ferret
Breed
*
Age
*
Years/Months?
*
Years
Months
Weight
*
Weight Unit of Measurement
*
lbs
kg
Patient's Blood Pressure:
*
Taken
Was Not Taken
Systolic BP
Additional BP Information (If Available)
Sex
*
M
F
MN
FS
Location of pet (in hospital)
*
Department/Service Requesting Consult
Veterinarian Requesting Consult
Requested Date of Completion
Date Format: MM slash DD slash YYYY
Attending Veterinarian on Day of Consult
Best number to contact attending veterinarian or staff
Best email to forward results:
*
Primary Care Practice Name:
*
Primary Care Veterinarian's Name:
*
Other Practices:
Client's Preferred Pharmacy:
Owner Preferred Pharmacy/pharmacies:
Alternate Veterinarian or Specialist Name and Practice
*
Reason(s) for Referral:
*
New Murmur
Longstanding Murmur
Preanesthesia Screen
Respiratory Signs
Arrhythmia
Syncope
Suspected CHF
Hypotension
Hypertension
Fluid Tolerance Screen
Pericardial Effusion
Pleural Effusion
Abdominal Effusion
Other (Please Explain Below)
Brief Reason for Referral
*
Please describe in a few sentences the reason for referral.
Important Note:
CVCA cardiology consultation, including examination, echocardiogram +/- ECG will range from $690 - $865 ($685-$860 TX)($678.40-$863.90 LV incl tax). Please note that some patients require additional care. If patient is hospitalized, charges may be accrued for CVCA recheck exams each additional day pet is in the hospital.
Bill to:
*
Bill to Service (Do not select if Louisville, KY)
Charge to Client's CareCredit
Charge to Client's Credit Card
Client to pay online (Louisville, KY ONLY)
I have quoted the clients CVCA's consult range of $678.40-$863.90 and instructed them to apply a deposit of $646.60 online at cvcavets.com or https://www.cvcavets.com/payonline/.
*
Please input your initials.
I have quoted the clients CVCA's consult range of $678.40-$863.90.
*
Please input your initials.
I have quoted the clients CVCA's consult range of $690.00-865.00.
*
Please input your initials.
I have quoted the clients CVCA's consult range of $685.00-860.00.
*
Please input your initials.
Please provide client payment information to CVCA staff member.
Client Email Address
*
Amount Charged to Client's Credit Card (Deposit)
*
Amount Charged to Client's Credit Card (Deposit)
*
Amount Charged to Client's Credit Card (Deposit)
*
Total Payment
$0.00
Credit Card
*
American Express
Discover
MasterCard
Visa
Card Number
Expiration Date
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
Security Code
Cardholder Name
Required Documents (Upload here or email)
Please attach the following documents OR send via email to your CVCA office. PLEASE NOTE: Lack of this information may delay cardiac evaluation and/or final report.
Referral Summary/SOAP
Referral Summary or SOAP
I have emailed the referral summary separately to my chosen CVCA location.
Pending-Summary included above.
Blood Work
Most Recent Blood Work
I have emailed Blood Work separately to my chosen CVCA location.
No blood work available
Blood work pending
Radiographs
Radiographs
I have emailed radiographs separately to my chosen CVCA location.
No radiographs available
Radiographs available on shared internal server
Radiographs are on film
Additional Documents
File
File
File
File
File
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