Mobile Echo Request - Veterinary Cardiology of Orange County

For referring veterinarians, please fill out this form, and we will contact you shortly to schedule an echocardiogram appointment at your hospital. Fields marked with an asterisk (*) are required. Please note that this form is not for pet owners.

Type of Study Requested

Mobile echocardiogram

Mobile echocardiogram w/ X-ray review

Mobile echocardiogram w/ additional mobile ECG

Mobile echocardiogram w/ X-ray review and additional mobile ECG

Referring DVM Name(Required)

First Last

Clinic Name*(Required)

rDVM Email (for formal report)(Required)

rDVM Phone #(Required)

Patient Information

Patient Name(Required)

Owner Name(Required)

First Last

Breed(Required)

Age(Required)

Sex(Required)

Male

Female

Body Weight (kgs)(Required)

Patient history and reason for referral(Required)

Patient medications (include dose/frequency)(Required)

Lab work performed — include date, type, kidney values (even if normal), and any abnormal values(Required)

Do you have chest X-rays for us to review with the echo study, or do you plan to take X-rays on the same day as the echo? If so, let us know if past or planned x-rays, the date of the study (or projected date), and findings (if applicable), and send DICOM images to info@vetcardiologyoc.com

Was blood pressure testing performed, and if so, what was the date of the study and findings?(Required)

Other salient diagnostic test results or other information?