Cardiology and Cardiac Surgery Appointment and Procedure Request Form

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What are you interested in today?(Required)

Who is filling out this form?(Required)

We are currently only receiving referrals from cardiologists for open-heart surgeries. Learn more about open-heart surgery at the CSU Veterinary Health System.

Patient Information

Patient Name(Required)

Breed(Required)

Color(Required)

Date of birth(Required)

Weight (kg)(Required)

Patient Information

Patient Name(Required)

Breed(Required)

Color(Required)

Date of birth(Required)

Weight (kg)(Required)

Patient Information

Patient Name(Required)

Breed(Required)

Color(Required)

Date of birth(Required)

Weight (kg)(Required)

Owner Information

Phone(Required)

Email(Required)

Owner Information

Phone(Required)

Email(Required)

Owner Information

Phone(Required)

Email(Required)

Primary Care Veterinary Information

Primary Vet Clinic Name(Required)

Vet Name(Required)

Phone(Required)

Email(Required)

Please ask your veterinarian or cardiologist to email your pet’s medical records to [email protected].

Primary Care Veterinary Information

Primary Vet Clinic Name(Required)

Vet Name(Required)

Phone(Required)

Email(Required)

Primary Care Veterinary Information

Primary Vet Clinic Name(Required)

Vet Name(Required)

Phone(Required)

Email(Required)

Veterinary Specialist Information

Cardiologist / Specialist Name(Required)

Practice Name(Required)

Email(Required)

Phone(Required)

Veterinary Specialist Information

Cardiologist / Specialist Name(Required)

Practice Name(Required)

Email(Required)

Phone(Required)

To expedite procedural scheduling, please ask your veterinarian’s office to send your animal’s medical records to [email protected].

Veterinary Specialist Information

Cardiologist / Specialist Name(Required)

Practice Name(Required)

Email(Required)

Phone(Required)

To expedite procedural scheduling, please ask your veterinarian’s office to send your animal’s medical records to [email protected].

Diagnosis/Disease Information

What is their specific diagnosis?(Required)

Date of diagnosis(Required)

Current symptoms(Required)

Examples include but are not limited to: lethargy, exercise intolerance, collapse, etc.

Reason for inquiry(Required)

To schedule your appointment, do you have a preferred day or time, or would you like the next available opening?

CSU Cardiology sees new appointments Monday-Thursday, from 9 a.m.-2:30 p.m.

Diagnosis/Disease Information

What is the patient's specific diagnosis?(Required)

Date of diagnosis(Required)

Current symptoms(Required)

Examples include but are not limited to: lethargy, exercise intolerance, collapse, etc.

Current medications and dosages(Required)

What procedure(s) and date(s)?(Required)

Reason for inquiry(Required)

Diagnosis/Disease Information

What is the patient's specific diagnosis?(Required)

Date of diagnosis(Required)

Current symptoms(Required)

Examples include but are not limited to: lethargy, exercise intolerance, collapse, etc.

Current medications and dosages(Required)

What procedure(s) and date(s)?(Required)

Reason for inquiry(Required)

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Cardiology and Cardiac Surgery Appointment and Procedure Request Form

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Appointment and procedure request form

Patient Information

Patient Information

Patient Information

Owner Information

Owner Information

Owner Information

Primary Care Veterinary Information

Primary Care Veterinary Information

Primary Care Veterinary Information

Veterinary Specialist Information

Veterinary Specialist Information

Veterinary Specialist Information

Diagnosis/Disease Information

Diagnosis/Disease Information

Diagnosis/Disease Information

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