Cardiac Ultrasound Referral Form

Any information that is not on the referral document will not be sent to the radiologist and therefore a less complete study will result.

 

Dr. Litchfield will not be going over results with clients.

 

Which practice would you like to register with?

Today

REFERRING VETERINARIAN INFORMATION

CLIENT INFORMATION

PATIENT INFORMATION

Cough
Syncope
Exercise Intolerance
Tachycardia
Weight Loss

i.e HCM, DCM, Mitral Valve disease, Endocarditis

Patient Temperament

Cardiac Ultrasounds: Patients should only be fasted if it is suspected they will require full sedation (fractious cats, very anxious or aggressive dogs).

 

INFORMATION FOR REFERRING VETERINARIANS

Sedation Protocols

 

Light sedation such as butorphanol is often administered to keep patients calm and to provide pain relief during ultrasounds. Each patient will be assessed for their individual needs at the time of study. Fractious or highly stressed patients may receive further sedation to accommodate scanning and limit stress. Cardiac safe protocols are used such as midazolam/alfaxan for echos, only if patient requires. If you are declining sedation options as deemed necessary at the time of study, the study may not go forward or limited images may be taken.

Please advise if there are any contraindications to known sedation or previous reactions:

Please advise client to give any oral anti-anxiety meds as directed prior to their visit.
 

  • Added fee for blood pressure measurement
  • Added fee for EKG


A cancellation fee of $50 will be billed to clients who do not provide notice within 24 hours.

I would like the results sent to me via

DOCUMENTS


i.e. bloodwork, medical history, etc.

Thank you for entrusting us with the care of your patient. We are happy to answer any questions you may have. A member of our team will reach out to you as soon as possible.

 

 

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