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Referring veterinarian name *

number that referring

Referring veterinarian phone number

Referring veterinarian email address *

Pet owner's full name *

The name of the pet's owner, so that we know who to address when arranging your requested scan.

Owner's phone number

Owner's email address

Patient's name *

Name of the animal you are referring.

Breed

Examination requested

• Echocardiogram
• ECG

Location requested *

• Bromley Echocardiography clinic, BR2 9JF
• My own veterinary practice

We cannot guarantee that we will be able to travel to your location in the timeframe you require. Please select our Bromley location wherever possible. If you select your own practice, we will contact you within 8 working hours to arrange.

Background / reason for referral

E.g. This dog has a grade 3 murmur and I would like to rule out valve disease.

The patient I am referring is stable and can safely be seen outside of a clinical environment. I understand that if my patient requires sedation, I must arrange for this, as no drugs are held on site at the echo clinic. *

• Yes

We are unable to see acutely unwell patients. Your patient must be able to tolerate gentle restraint on an echo bed for at least 15 minutes. For some patients, particularly cats, you might wish to provide light sedation for the owner to administer ahead of their appointment.

Submit

If your patient can be seen at our Bromley clinic, we will arrange this with the owner within 8 hours of receiving your request. We will then confirm this appointment with you, so that you can bill your client.

If your patient cannot travel to Bromley, we will contact your practice - not the owner - to arrange a day and time.