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Tuesday Echo Clinic - Patient Form

**TO BE COMPLETED BY A REGISTERED VETERINARIAN**

Date/Time: Tuesdays, 3-6pm

Location: Lauzon Veterinary Hospital

Billing: Direct to the client

Report: Sent the next business day to the email on this form

Book appointment. Please ensure an appointment is booked prior to submitting this form. Book by calling Lauzon Animal Hospital at 519-948-7727.
Submit Form. Complete this form prior to appointment.
Optional: Email supplemental patient details (relevant bloodwork, ECG, xrays, etc) to info@heartsandtails.ca.

SEDATION NOTE: Sedation must be prescribed by the referring vet.

Thank you!

Hearts & Tails
519-791-0529
Heartsandtails.ca

REFERRING VETERINARIAN INFORMATION

Referring Clinic Name *

Referring Veterinarian *

Email *

Referring veterinarian/clinic email to receive the report.

When is the appointment date? *

Please book an appointment prior to submitting this form.

What service is this for? (Billed to the client) *

Echo ($700)
Echo & ECG ($800)

Patient's First & Last Name *

Date of Birth *

Species *

Breed *

Gender *

Weight (indicate kgs or lbs) *

Reason for Referral *

Additional Clinical Exam Findings/Cardiac History

Will the patient be sedated for the test? *

If yes, please prescribe prior and list sedations used.

Will supplementary patient details (radiographs, labs, etc) be submitted for the cardiologist to review with the case? *

Yes
No

If yes, please send via email to info@heartsandtails.ca.

Other Information/Comments

Security Question *

I HAVE READ AND UNDERSTOOD THE PRIVACY POLICY *