Consult – Internal Request Consult – Internal Request Home » Consult – Internal Request Consult - Internal Request This form is for associated services within CVCA-affiliated hospitals ONLY. If you are a referring DVM, please use the referral form at https://www.cvcavets.com/for-veterinarians/refer-a-patient/. You must select a location below to ensure CVCA receives this form.Select a State:*CaliforniaColoradoFloridaKentuckyMarylandNorth CarolinaOregonTexasVirginiaMassachusettsMaryland*Please select the office you are referring to: Annapolis, MD Columbia, MD Frederick, MD Gaithersburg, MD Rockville, MD Hunt Valley, 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 Massachusetts*Please select the office you are referring to: Waltham, MA North Carolina*Please select the office you are referring to: Cary, NC Knightdale, NC Florida*Please select the office you are referring to: West Palm Beach, FL California*Please select the office you are referring to: San Juan Capistrano, CA Lawndale, CA Texas*Please select the office you are referring to: Austin-Northwest Austin-Shoal Creek TeleCardiology by CVCA - Dallas/Flower Mound Oregon*Please select the office you are referring to: Portland-Milwaukie Portland-Hollywood Colorado*Please select the office you are referring to: Alameda East Boulder Loveland Wheat Ridge Do you need a consult for a patient who has already visited TeleCardiology by CVCA?* Yes No Please fill out our TeleCardiology Follow-Up Consult Request instead. Owner Name (First and Last)* First Last This field is hidden when viewing the formPrevious Name Field (Ignore)Best # for Client*This field is hidden when viewing the formPrevious # Field (Ignore)Address* Street Address City State Zip Home Phone*Work PhoneEmail* Current CVCA Client:* Yes No Patient Name*Age*Years/Months?*YearsMonthsSex* M F MN FS Species* K9 Feline Ferret Breed*Weight*Weight Unit of Measurement*lbskgPatient's Blood Pressure:* Taken Was Not Taken Systolic BPAdditional BP Information (If Available)Please write below any specific comments or questions you may have for the cardiologist.Follow-up preference to your office Call Email Location of pet (in hospital)*Department/Service Requesting ConsultVeterinarian Requesting ConsultRequested Date of Completion MM slash DD slash YYYY Attending Veterinarian on Day of ConsultBest number to contact attending veterinarian or staffBest 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*Is this an URGENT (same-day) request?* Yes No 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. In the event of a situation where the patient needs CPR to be performed, please indicate the owners' preference:* Yes, please perform CPR No, do not recusitate Price range for consultationCVCA cardiology consultation, including examination, echocardiogram +/- ECG will range from $910.00 - $1134.00 pre-tax (Louisville: $889.34 -$1126.78 with 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. Price range for consultationThe cost of a cardiology consultation with an echocardiogram is $910.00. If an electrocardiogram is also indicated, there will be an additional cost of $224.00. Please advise clients of the estimated range of $910-$1134.Bill to:* Bill to Service (Do not select if Louisville, KY) Charge to Client's CareCredit Client Credit Card (Please provide information to CVCA Staff Member) I have quoted the clients CVCA's consult range of $889.34 -$1126.78 (with tax).*Please input your initials. I have quoted the clients CVCA's consult range of $910-$1134.*Please input your initials. I have quoted the clients CVCA's consult range of $910-$1134.*Please input your initials. I have quoted the clients CVCA's consult range of $969-$1207.*Please input your initials. Please provide client payment information to CVCA staff member. 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/SOAPReferral Summary or SOAPMax. file size: 30 MB.Referral Summary Status SOAP uploaded above. Pending-Summary included above. I have emailed the referral summary separately to my chosen CVCA location. Please list the medications the patient is taking.*Blood WorkMost Recent Blood WorkMax. file size: 30 MB.Blood Work (Description)* I have emailed Blood Work separately to my chosen CVCA location. No blood work available Blood work pending What type of bloodwork are you sending/will you send to CVCA?*RadiographsRadiographsMax. file size: 30 MB.Radiographs (Description)* I have emailed radiographs separately to my chosen CVCA location. No radiographs available Radiographs available on shared internal server Radiographs are on film Type of Radiographs?* Chest Radiographs Abdominal Radiographs Additional DocumentsFileMax. file size: 90 MB.FileMax. file size: 90 MB.FileMax. file size: 90 MB.FileMax. file size: 90 MB.FileMax. file size: 90 MB.
