Referral Form

For internal medicine referrals, or Aquavet hydrotherapy referrals, please visit our separate forms here:

Please note outpatient CT scanning results will be returned within 7 working days, or sooner if requested. This service is for referring vets who wish to continue to manage their own cases.

Client Details

Client Name:

Pet Name:

Client Email:

Client Telephone Number:

Vet Details

Name of Referring Practice:

Practice Email:

Practice Telephone Number:

Name of Referring Vet:

Referral Details

Please select which department would you like to refer to? :

Has this case been discussed with a specific clinician?:

If answered yes, please state their name:

Please can you briefly write what diagnostic testing you have done such as radiographs or bloods (This assists us in requesting all relevant history) *Required:

Could you give us a few details about the referral you are making? *Required:

Attachments

Please attach the appropriate case history and any additional records e.g. test results, radiographs, ECG tracings etc (Max total file size 8MB).

Attach Animal History*:

Attach Animal History:

Pet Details

*All fields are mandatory*

Pet's Sex:

Pet Species:

Pet Breed:

Pet's Age:

Financial Details

*All fields are mandatory*

Is the pet insured?:

Insurance Company Name:

Policy Number:

Policyholder Name:

Security Question:

Select a surgery:

I have read and agreed to the privacy notice: