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4176 Meridian Street

Bellingham, WA 98226

(360) 758-2200

24/7 Emergency Care

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Referral Requests
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Medical History Cardiology Form

Medical History: Cardiology Initial / Recheck (Bellingham)

4176 Meridian St, Bellingham, WA 98226 | Phone: 360-982-0166 | FAX: 1-888-867-6928 | bbvsh.com/bellingham | bellingham@bbvsh.com
Health Check
During the COVID-19 outbreak, the health and safety of our clients, patients, employees, doctors and our community is paramount.
Have you travelled to any countries outside the United States (including Canada) within the last 14 days?*

YesNo
Did you provide care or have close contact with a person with COVID-19 (probable or confirmed) while they were ill (cough, fever, sneezing, or sore throat) within the last 14 days?*

YesNo
Did you have close contact with a person who travelled outside of the United States in the last 14 days who has become ill (cough, fever, sneezing, or sore throat)?*

YesNo
Have you or anybody in your home had contact with someone who is being tested for COVID-19 or who has been diagnosed with COVID-19?*

YesNo
Contact Information
Your name*
Your email
Optional: If you enter in your email, we will send you a copy of this form to you.
Phone number where you can be reached today*
(XXX) XXX-XXXX
Your pet's name*
What is the present complaint?*
Primary concern, reason for visit
When was this first noticed/diagnosed?*
Has this gotten worse, better, or stayed the same?*
Please describe how.
Has your pet ever seen another cardiologist?*

YesNo
Who? Where?*
Name of doctor, name of clinic
Does your pet have any other current or historical health issues?*
If your pet eating and drinking normally?*

YesNo
Please describe:*
What is abnormal?
What is the name of your pet's current diet? *
Have you fed your pet a diet labeled as "grain-free" within the past year?

YesNo
Do you feel your pet is breathing normally at home?

YesNo
Please describe:*
What abnormalities you have seen?
Is your pet coughing?*

YesNo
How frequently is this occurring?*
Has your pet had any episodes of weakness/collapse?*

YesNo
Please describe the episode(s)*
How frequently has this occurred?*
Have you monitored breathing rates while your pet is asleep?*

YesNo
What's the average rate?*
Has the rate been increasing?*

YesNoOther
Is your pet receiving any medications?*

YesNo
What is the name of the medication(s), the dose and the frequency?*
e.g. 'prednisone 5 mg tabs,½ tab once daily for 3 months'
You can also upload photos, if easy & convenient:

Cancelof
Since the medications were started, has your pet's condition...*

ImprovedWorsenedRemained the sameOther
Are any surgeries or dentistries planned?*

YesNo
Has your pet ever had a negative reaction to any medications?*

YesNo
Please describe:*
Which medication(s) caused the reaction? What was the reaction?
Is there anything else you wish us to know?*
temperament, previous issues, etc.
OPTIONAL: HOW DID YOU FIND US?
Help us understand the specifics of how you discovered us for cardiology treatment for your beloved pet:
e.g. I searched Google for 'cardiology vet wa'; My vet recommends you for cardiology
Could this form be better? Share your thoughts with marketing@bbvsh.com
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Boundary Bay is a Veterinary Hospital in Bellingham providing advanced specialty care and 24/7 emergency veterinary services, giving pet owners peace of mind while supporting referring primary care veterinarians.

Bellingham Veterinary Specialty Hospital

4176 Meridian Street
Bellingham, WA 98226

P: (360) 758-2200
F: 1 (888) 867-6928
E: bellingham@bbvsh.com

Web: bellingham.bbvsh.com

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© Boundary Bay Veterinary Specialty Hospital. All rights reserved.

Contact BBVSH Bellingham

Please fill in your contact details and a message below. We’ll be sure to contact you within the next business day.

Alternately, call (360) 758-2200, email bellingham@bbvsh.com, or fax 1 (888) 867-6928.

If you have an emergency, please call (360) 758-2200.

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