Consult - Internal Request - | CVCA Cardiac Care for Pets

You must select a location below to ensure CVCA receives this form.

Select a State:*

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

Hidden

Previous Name Field (Ignore)

Best # for Client*

Hidden

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?*

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)*

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:

Owner Preferred Pharmacy/pharmacies:

Alternate Veterinarian or Specialist Name and Practice*

Reason(s) for Referral:*

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 $678.40 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)*

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

Max. file size: 30 MB.

I have emailed the referral summary separately to my chosen CVCA location.
Pending-Summary included above.

Blood Work

Most Recent Blood Work

Max. file size: 30 MB.

I have emailed Blood Work separately to my chosen CVCA location.
No blood work available
Blood work pending

Radiographs

Max. file size: 30 MB.

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

Max. file size: 16 MB.

File

Max. file size: 16 MB.

File

Max. file size: 16 MB.

File

Max. file size: 16 MB.

File

Max. file size: 16 MB.

Consult – Internal Request