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CHESTER BASIN
ANIMAL HOSPITAL
133 Highway 12
Chester Basin NS B0J 1K0
info@cbah.ca
902-275-3551
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CARDIOLOGY REFERRAL FORM
INFORMATION FOR REFERRING VETERINARIANS
Referring Hospital Information
Hospital Name
Referring Veterinarian
Phone
Fax
Email
Client Information
Client Name
Client Address
Client Phone
Client Email
Patient Information
Patient Name
Species
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Breed
Age
Date of Birth
Sex
Male
Female
Patient is spayed/neutered
Current Weight (kg)
Reason for consultation
Heart Murmur
Arrhythmia
Syncope/Weakness/Collapse
Preanesthetic Evaluation
Respiratory Signs (cough/tachypnea, etc)
Exercise Intolerance
Cardiology Recheck Evaluation
OFA Evaluation (breeding animals only)
Breed Screening (cardiomyopathy, etc)
Services requested
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Please provide a brief, pertinent history
Current Medications (include dose and frequency)
Recent Diagnostic Testing (include date and results or attach if possible)
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