Vet Referral Form
A member of our Vethub team is standing by to receive your referral and emergency requests, please complete the Vet Referral Form which is divided into three sections: Priority, Owner Details and Patient Details.
Part One: Priority
Help us to understand the urgency of your request
When is this appointment needed?
*
Click to select
Critical - Appointment within the next 24hrs
Urgent - Appointment within the next five days
Next available appointment
Discipline name
*
Click to select
Internal Medicine
Endocrinology
Cardiology
Urology
Oncology
Dermatology
Medical Neurology
Orthopaedic Surgery
Soft Tissue Surgery
Surgical Neurology
Equine Medicine
Large Animal Surgery
Farm Animal
Reproduction
Rehabilitation
Referring Vet Name
*
First Name
Last Name
Referring Practice Name
Referring Vet Email
*
example@example.com
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Part Two: Owner Details
Please provide client contact details so we may register the appointment and contact your client
Owner's Name
*
Ms.
Mrs.
Mr.
Dr
Prof.
Prefix
First Name
Last Name
Address
*
Address Line 1
Address Line 2
County
Eircode
Telephone Number
Mobile Number
*
Additional Contact Number
Additional Contact Name
First Name
Last Name
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Part Three: Patient Details
Please provide patient details
Patient's First Name
*
Species
*
Click to select
Canine
Feline
Equine
Bovine
Ovine
Caprine
Camelid
Porcine
Other
Breed
*
Age
*
-
Day
-
Month
Year
Date
Patient Weight in kgs
Has this patient been referred to UCDVH previously?
*
Yes
No
Is the patient Neutered?
*
Yes
No
Is the Animal Insured?
*
Yes
No
If insured, please select company name or select "Not Insured"
*
Please select
Allianz Petplan
Petinsure.ie
Petinsurance.ie
An Post
Other
Not Insured
Upload Documents
In order to accurately process your referral request, please describe the condition and reason for referring the patient. Patient history records must be included in this submission
Describe the reason for referral
*
Patient History
*
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Patient History
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Patient Laboratory Report
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Patient Diagnostic Images
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Patient Images / Videos
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Please verify that you are human
*
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