Cardiology Consultation / New Form

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Instructions

This service is for veterinarians only. If you are seeking medical advice for your own pet or animal, please contact your veterinarian. If this is an emergency, please call the main hospital at 217-333-5300.

Veterinarians, please answer the questions below to submit a consult request to the Cardiology Service at the University of Illinois Veterinary Teaching Hospital. File upload is optional. Please note that this is only for consultation and not a referral request. Please make sure to include the reason or specific clinical questions for your consultation.

Referring Vet Contact Information

First Name*

Last Name*

Clinic Name*

Phone*

Email*

Preferred Method of Contact*

Phone

Fax number

Patient Information

Name*

Date of Birth (mm/dd/yyyy)*

Species/Breed*

Weight (kg)*

Other Identifying Information

Patient History

Has the patient been seen by the University of Illinois VTH?*

Yes

Provide MR number if available

Is this a recheck follow up?*

Yes

Please provide a medical history.

What is your question? (i.e. reason for consultation)*

Heart rate*

Respiratory rate*

Murmur*

Yes

Maybe

Characterize the murmur (e.g. grade 3/6 left apical systolic heart murmur)

Arrhythmia*

Yes

Maybe

Coughing*

Yes

Thoracic radiographs*

Yes

ECG*

Yes

Bloodwork*

Yes

Image upload #1 (optional)

Supported image filed types: jpg, jpeg, gif, png, bmp

Image Upload #2

Supported image filed types: jpg, jpeg, gif, png, bmp

Image Upload #3

Supported image filed types: jpg, jpeg, gif, png, bmp

Link to Radiographs (url hyperlink)

Submit

When ready to submit, check the box below and hit save. If urgent, please contact the cardiology service at 217-333-5300. If you are having difficulty attaching files or submitting a consult, please email vthcardiology@vetmed.illinois.edu.

Ready to submit*

Cardiology Consultation

Invalid Fields

Instructions

Referring Vet Contact Information

Patient Information

Patient History

Submit

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