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Serving SW Missouri, NW Arkansas, NE Oklahoma, and SE Kansas
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(417) 622-1700
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Case Submission Form
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Echocardiograms
Abdominal Ultrasound
ECG Services
FAQs
For Pet Parents
Educational Resources
Contact Us
Home
About
Services
Echocardiograms
Abdominal Ultrasound
ECG Services
FAQs
For Pet Parents
Educational Resources
Contact Us
Case Submission Form
Case Submission Form
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Case Submission Form
Case Submission Form
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Name of Clinic
Ordering Veterinarian
Phone
Email
Name of Pet
Owner's Name
Age
Years
Months
Species
- Select -
Canine
Feline
Breed
Gender
- Select -
Female
Female Spayed
Male
Male Neutered
Pet Weight
Weight Unit
- Select -
Kilograms (kg)
Pounds (lbs)
Current Medications
Requested Testing
- Select -
Echocardiogram
ECG
Echocardiogram + ECG
Abdominal U/S - Limited
Abdominal U/S Complete
Has patient had recent thyroid blood work?
Yes
No
Results:
Normal
Abnormal
In cardiac cases with suspected diet related concerns, please provide current diet and duration. (optional)
Reason for Exam
Pertinent History
Any ABNORMAL results: (PE, CHEM, CBC, UA, X-rays)
Does pet have a current heartworm test?
Yes
No
Result:
Positive
Negative
Are there radiographs for submission?
Yes
No
Attach abdominal radiographs here (JPEG format preferred):
If radiographs are not available in JPEG format, please send a DICOM viewer link, as you normally would when sending radiographs, to our email address at:
[email protected]
Choose File
Radiographs sent to email
Radiographs sent to email
Please attach complete medical records including lab work from the last 2 years
Choose File
What email address would you like the report to go to:
Do you have any specific case questions or concerns to ask the cardiologist?
SUBMIT REQUEST
