Echocardiogram Referral in Branson, MO

Referring Veterinary Clinic*

Referring Veterinarian*

Please indicate the e-mail address for forwarding the cardiologist report.*

Client Name*

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Client Phone Number*

Client Email Address*

Patient Name*

Patient Species*

Canine
Feline

Patient Breed*

Patient Sex*

Intact Female
Spayed Female
Intact Male
Neutered Male

Patient Age (years)*

Patient Weight (lbs)*

Relevant Patient History & Reason for Echo*

Heart Murmur*

Please summarize abnormal lab results*

Per the policies of Oncura Partners, submitting radiographs for review requires DICOM images. If these images are taken more than 24 hours prior to the ultrasound, there is an additional contrast fee.

Please submit abnormal lab results here

Max. file size: 256 MB.

List all current medications and dosages. State when medications were started.*

Blood Pressure Measurements:*

Has the patient ever been diagnosed with congestive heart failure?*

Yes
No

If yes, please give a detailed explanation. If no, type N/A.*

Does the patient have any upcoming scheduled procedures that will require anesthesia?*

Yes
No

Does the patient have a history of aggressive behavior our team should be aware of?*

Yes
No

If yes, please give a detailed explanation.*

Is the patient's rabies vaccination status up-to-date?*

Yes
No

Please select which service is to be performed by Animal Care Clinic.*

Echocardiogram w/Cardiologist Interpretation
Echocardiogram + Chest X-rays w/Cardiologist Interpretation
Echocardiogram, Chest X-rays, & ECG w/Cardiologist Interpretation

Please prescribe gabapentin at 20mg/kg PO to be given 4 hours prior to echocardiogram visit.

Please instruct your client to call us to schedule the ultrasound exam. Our phone number is (417) 334-7696.

Echocardiogram Referral

This service is temporarily unavailable.

Echocardiogram Referrals