Cardiology Referral Form

This form is for veterinarians to submit patient and client information for non-emergency referrals.

If you want to refer a case with known or suspect heart disease on an emergency basis, please call the NC State Small Animal Emergency Service at (919) 513-6911 to speak to an ER team member.

Please provide a brief summary of the patient’s history, exam and diagnostic findings and treatments so that we can schedule your patient according to its level of urgency. Provide any hospital notes, laboratory or diagnostic results which can be attached below. You may also send us previous test results, links to images to our service email at ncstatecardiology@ncsu.edu. Alternatively, large files such as DICOMS or CT scans can be submitted directly to us through our server (see instructions on main information for Referring Veterinarians page).

Veterinarian Contact Information

Referral Status(Required)

Expedited Referral

Standard Referral

Veterinarian to Contact(Required)

Prefix First Last

Clinic Name(Required)

Clinic Phone Number(Required)

Clinic Email(Required)

Clinic Fax Number

Owner Contact Information

Client Contact(Required)

I have asked client to call VH

Please call client for appointment.

Name of the owner(Required)

First Last

Owner Phone(Required)

Owner Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Information about the patient

Has this patient ever been seen by any service at NC State Veterinary Hospital?(Required)

Yes

Not Sure

Patient/Pet Name(Required)

Species(Required)

Gender(Required)

Breed(Required)

Date of Birth or Age(Required)

Weight (lbs/kgs)(Required)

Color(Required)

Reason for referral/clinical history (include duration of illness, signs)(Required)

Are you sending any diagnostic tests, such as previous radiographs, echo or bloodwork, with this patient. If so, please list below(Required)

Vaccination History (please enter date administered)

Canine Rabies(Required)

DHPP(Required)

Leptospirosis(Required)

Feline Rabies(Required)

FVRCP(Required)

FeLV(Required)

Medical reason precluding rabies vaccination (if any):(Required)

Other Vaccines and Date Administered:(Required)

Vaccines and Date Administered:(Required)

File attachments

Please attach the results of any diagnostic test, such as previous radiographs/radiographic reports, echo reports, blood work.

Drop files here or

Max. file size: 195 MB.

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