Equine Referral

PRACTICE DETAILS

Veterinary Surgeon *

Practice *

Town *

Postcode *

Phone Number *

Practice email address (for sending letters / reports etc)

Veterinary surgeon's email address *

OOH service provider

OWNER DETAILS

Title

First Name *

Surname *

Address

Street Address

Town

County

Postcode

Telephone 1

Telephone 2

PATIENT DETAILS

Pet Name

Species *

Sex

Neutered / Spayed

Yes

Breed

DOB

Colour

Insured *

Yes

REFERRAL DETAILS

Case Summary *

Please concisely outline the reasons for referral (not the entire history) - we really need this information to assess the case. Photos are very helpful for ophthalmology cases (attach below).

Type of referral *

Routine

Urgent (1-2 days)

Same day emergency

OOH Emergency

OOH Emergency is Ophthalmology only. (Weekdays after 17:30hrs / weekends / public holidays). If your referral is an OOH Emergency, please telephone us as well on 01803 467333.

Speciality required

Ophthalmology

Patient history

Please attach patient history and any relevant reports, photos, radiographs etc. (FULL PATIENT HISTORY FROM BIRTH is required for us to be able to process insurance claims). Choose a file and then upload it. Repeat process for each file.

Add a new file

Files must be less than 8 MB.
Allowed file types: gif jpg jpeg png txt pdf doc docx.

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Equine Referral

Address

Contact

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