EMERGENCY
| 780-570-9999
Submit a Referral
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Menu
Home
About
Meet Our Team
Careers
Contact
Departments
Cardiology
Dentistry & Oral Surgery
Diagnostic Imaging
Emergency and Critical Care
Internal Medicine
Neurology
Ophthalmology
Surgery
Pet Owners
What To Expect
Referral Process
Pet Admission Forms
FAQ
Orthopedic Foundation for Animals (OFA)
Veterinarians
Submit a Referral
Continued Education
Testimonials
EMERGENCY
| 780-570-9999
Submit a Referral
Cardiology Questionnaire
Cardiology Questionnaire
Step
1
of
2
50%
Date
*
MM slash DD slash YYYY
Client Information
Last Name
*
Primary Phone Number
*
Email Address
*
Do you have medical insurance for your pet?
*
Yes
No
What company is it with?
*
Patient Information
Pet Name
*
Date of Birth
*
MM slash DD slash YYYY
Breed
Gender
*
F
FS
M
MN
Is your dog a working-dog?
*
Yes
No
What type of work?
*
Please explain
Has your pet traveled outside of Alberta in the last year?
*
Yes
No
If so, where did your pet travel?
*
Is your pet taking any medications?
*
Yes
No
Which medication is your pet currently taking?
*
Is your pet allergic or intolerant to any food or medications?
*
Yes
No
What diet(s)/ treats does your pet eat?
Has your pet’s appetite:
*
Decreased
Increased
No Change
Has your pet’s water consumption:
*
Decreased
Increased
No Change
Has your pet’s exercise:
*
Decreased
Increased
No Change
Has your pet been coughing?
*
Yes
No
When does your pet cough (click all that apply)
*
Morning
Evenings
With exercise
After eating
No pattern/ randomly
Has your pet experienced a collapsing episode?
*
Yes
No
Was this after exercise?
*
Yes
No
Has your pet ever experienced difficulty/ rapid breathing?
*
Yes
No
Is there anything we should know prior to the appointment?
