Emergency Referrals

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Please note that once we have reviewed this case, we will contact the practice to advise that we have accepted this emergency referral.

Please advise the client that we will ask for 50% of estimated costs to be paid upon admittance unless their pet is insured with Pet plan.

Practice Details

Veterinary Surgeon*

Practice*

City*

Postcode*

Phone Number*

Email*

Owner Details

Please leave non-mandatory fields if they are in the patient history.

Title

First Name or Initial*

Surname*

Address Line 1

Address Line 2

Address Line 3

City

County

Postcode

Telephone Number*

Mobile Number*

Patient Details

Please leave non-mandatory fields if they are in the patient history.

Pet Name*

Species

Sex

Neutered

Yes
No

Breed

Age

Colour

Referral Details

Brief summary of problem/reason for referral (Please always provide the full clinical history, lab results & any imaging relevant to the referral)*

Attach a File

Attach a Case Notes file

Attach Blood Results

Attach a Radiograph file

Insurance Details

Is the pet insured?

Yes
No

Insurance Company

Have you already submitted a claim?

Yes
No

If so, what did you claim?

Has the excess been paid?

Please note we will only direct claim with Pet Plan without prior arrangement and this is at the practices discretion. Would you prefer we contact yourselves or client to arrange the appointment?

Vet
Client

Security Question

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