Patient Referral Form
This form is for referring veterinarians only.
What would you like to do?
*
Book surgery
Book consultation
Submit post op radiographs
Request full written radiographic report (fees apply)
Request case advice (not ready to book surgery)
Clinic name
*
Vet's name
*
Clinic email
*
example@example.com
New or existing patient (for Specialist Surgical Solutions)
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New patient
Existing patient (a 'new patient' form has previously been submitted for this patient)
Have you discussed costs and availability with the owner?
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Yes. The owner is aware of costs and ready to book next available
Yes. The owner is aware of costs but has specific date requirements
Availability notes - e.g. owner holidays, clinic schedule
Patient name - PLEASE INCLUDE SURNAME
*
Breed
*
Weight
*
Age
*
Gender
*
Female desexed
Female entire
Male desexed
Male entire
Body Condition Score
*
1/5
2/5
3/5
4/5
5/5
Owner full name
*
Owner email
*
example@example.com
Owner phone number
*
Type of surgery
*
Orthopaedic
Soft Tissue
Orthopaedic Procedures
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Tibial osteotomy (TTO/CWO)
Extracapsular suture
MPL
FHNO
Other / Unsure. Please leave a comment below
Is cranial drawer present?
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Yes
No
Not tested / unsure
Is the patella stable?
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Yes
No
MPL grade
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1
2
3
4
Unsure
Limb (select multiple if required)
*
Right
Left
Uncertain. Please leave a comment below
Soft Tissue Procedures
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Anal sacculectomy
Perineal hernia
Salivary gland removal
TECA BO
Other / Unsure. Please leave a comment below
Relevant clinical history - 200 words max. No radiographic findings here please. Upload supporting documents below if required
*
0/200
Post op progress e.g lameness score, patella stability, any other issues.
*
Comments
0/200
Upload supporting documents if applicable
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Upload radiographs if applicable. Please note more than SIX will incur an additional fee for radiograph reporting. Refer to price list. No more than SIX will be accepted for case advice.
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OR link to radiograph viewing platform if applicable
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