Consult - Internal Request | CVCA Cardiac Care for Pets

Select a State:*

Maryland*

Please select the office you are referring to:

Virginia*

Please select the office you are referring to:

Kentucky*

Please select the office you are referring to:

Lousiville, KY

Texas*

Please select the office you are referring to:

NW Austin, TX
Shoal Creek - Austin, TX

Department/Service Requesting Consult

Veterinarian Requesting Consult

Requested Date of Completion

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:

Current CVCA Client:*

Yes
No

Patient Name*

Species*

K9
Feline
Ferret

Breed*

Age*

Years/Months?*

Weight*

Weight Unit of Measurement*

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)*

Owner Name:*

Best # for Client*

Address*

Street Address City State Zip

Home Phone*

Work Phone

Email*

Owner Preferred Pharmacy/pharmacies:

Alternate Veterinarian or Specialist Name and Practice*

Reason(s) for Referral:*

Brief Reason for Referral

Important Note:

CVCA cardiology consultation, including examination, echocardiogram +/- ECG will range from $670 - $840 ($646.60 - $826.80 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
Charge to Client's CareCredit
Charge to Client's Credit Card

I have quoted the clients CVCA's consult range of $646.60-$826.80.*

Please input your initials.

I have quoted the clients CVCA's consult range of $670.00-$840.00.*

Please input your initials.

Please provide client payment information to CVCA staff member.

Client's First Name*

Client's Last Name*

Email Address*

Phone Number*

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Amount Charged to Client's Credit Card (Deposit)*

Total Payment

$0.00

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date 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

I have emailed radiographs separately to my chosen CVCA location.
No radiographs available
Radiographs available on shared internal server
Radiographs are on film

Consult – Internal Request

Important Note:

Required Documents (Upload here or email)

Referral Summary/SOAP

Blood Work

Radiographs