Referral

PRACTICE DETAILS

Referring Veterinary Surgeon

Referring Practice Details

Telephone

Fax

OWNERS DETAILS

Owners Name

Owners Address

Primary Telephone Number

Telephone (Day)

Telephone (Evening)

Mobile

PET DETAILS

Patient's Name

Species

Breed

Age

Sex

Weight

Patient History

Please attach your patient's history. Accepted formats are .png, .jpg, .gif, webp, .pdf. Attachments are limited to 6MB's in size.

INSURANCE & PRIORITY

Is The Pet Insured For Vet Fees?

Clinical Problem

Case Priority

Immediate (same day) Urgent (within 24 hours) Expedited (within three days) Routine (within two weeks)

Additional Support Files

Please attach supporting documents. Accepted formats are .png, .jpg, .gif, webp, .pdf. Attachments are limited to 6MB's in size.

OUTPATIENT IMAGING SECTION ONLY

Please fill in this section if you require your patient to be referred for outpatient advanced imaging ONLY. This includes a vet-check for sedation/anaesthesia suitability, appropriate anaesthesia, advanced imaging (CT/MRI) and external specialist interpretation with the report sent directly to your practice.

Do You Require Outpatient Imaging Only?

What Imaging Modality Do You Need?