Advice Request Form
A member of our team is standing by to receive your advice requests. Urgent Advice Requests will be responded to within 24hours, all other requests will be responded to within 5days of receipt.
Part One: Priority
Help us to understand the urgency of your request
How urgent is the advice needed?
*
Click to select
Critical - Response within the next 24hrs
General - Response within the next five days
Discipline name
*
Click to select
Internal Medicine
Endocrinology
Cardiology
Urology
Oncology
Dermatology
Medical Neurology
Orthopaedic Surgery
Soft Tissue Surgery
Surgical Neurology
Wound Management
Equine Medicine
Rehabilitation
Pain Clinic
Primary Vet Name
*
First Name
Last Name
Practice Name
Vet Email
*
example@example.com
Vets Phone Number
Please enter a valid phone number.
Preferred Advice Call Time
Please enter a preferred time to receive your advice call and we will try our best to facilitate this request Minutes Minutes Minutes
AM
PM
AM/PM Option
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Part Two: Owner Details
Please provide client contact details
Owner's Name
*
Ms.
Mrs.
Mr.
Dr
Prof.
Prefix
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
*
Sex
*
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
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 Advice or the Main Query
*
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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