4 Paws Imaging Centers Chicago - Holter Monitor Form

Date of Ultrasound Appointment (required - mm/dd/yyyy)

Clinic Name(Required)

Phone(Required)

Referring Doctor

Name Of Referring Doctor(Required)

First Last

I allow the 4 Paws Imaging Centers to contact me through text messages.

Yes

Clinic/Doctor Preferred Email for Results(Required)

Clinic/Doctor Additional Email(s) for Results (optional)

I understand that 4 Paws Imaging Centers will not be relaying results of this diagnostic to owner. They will perform the diagnostic, and return results to referring DVM to relay results to owner.(Required)

I Understand

Owner's name(Required)

First Last

Patient ID (this is the ID you use when entering patient data into X-Ray machine)(Required)

Patient Name(Required)

Date of Birth(Required)

Weight(Required)

Species(Required)

Sex (Please indicate patient's altered status)(Required)

Breed(Required)

Is patient up to date on a rabies vaccine?

Yes

If your patient is not updated on a rabies vaccine, please call 4 Paws Imaging at 630-746-1382 to discuss protocol

When was patient's last echocardiogram?

Was this echocardiogram performed with 4 Paws Imaging?

Yes

Please email us the most recent echocardiogram report to 4pawsimaging@gmail.com

Please note echocardiograms need to be from the last 3 months. Please call us with any questions on this (630) 746-1382

Murmur Grade?

Pertinent History (Please include presenting clinical signs, even if normal)

Current Medications

*Please indicate the start date of all cardiac medications.

Differentials

Are there radiographs to submit for interpretation along with this ultrasound?

Yes

Date radiographs were taken:

6 radiographs max
Additional fee applies
Must be sent in dicom format to our server
Radiographs older than 2 weeks will not be accepted