Referral Request Form
Type of speciality required:
*
Please Select
Cardiology
Dermatology
Endoscopy
MRI
Neurology
Oncology
Ophthalmology
Orthopaedic
Radiography
Ultrasound
Physiotherapy
CT
Other
Specify the Required Speciality
Specialist you wish to refer to: (Name)
Date of request
-
Month
-
Day
Year
Date
Referring clinic information
Clinic Name
*
Clinic Branch
Contact number (calls)
*
Email address
*
example@example.com
WhatsApp number
Have you referred to us before?
Please Select
Yes
No
Referring Veterinarian details
Veterinarian Name
First Name
Last Name
Preferred contact method
Please Select
Call
Whatsapp
Email
Enter contact details
Client details
Client Full Name
*
First Name
Last Name
Client Phone Number
*
Client Email address
*
example@example.com
Patient details
Patient Name
*
Patient Species
Please Select
Dog
Cat
Other
Patient Breed
Patient Gender
Please Select
M
F
MN
FS
Patient Age
*
Current weight (KG)
Patient microchip number
Presenting Problem
Current diagnosis (if any)
Brief Medical History
Please attach the medical history
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Reason for referral (please state any specific diagnostics, procedures or requests here. If requesting diagnostic imaging, please mention the area to be imaged)
Current Medication
Rows
Medication
Dose
Frequency
Last dose administered
1
2
3
4
5
6
For ultrasound referrals, please confirm that the owner has been informed that clipping of fur will be required, and that they give consent
*
Yes, owner has been informed and gives consent
Not applicable - no ultrasound being performed
CT referrals - please select the region to be scanned
Head
Carpus / Foot
Thorax
Pelvis / Hips
Abdomen
Stifle
Shoulder
Tarsus / Foot
Elbow
Spine C1 - T2
Spine T3 - Tail
BOAS
Small mammal teeth
Others
Specify Other
MRI referrals - region to be scanned
C1-5
C6-Th2
Th3-L3
L4-S3
Head - CNS and Ears
Splanchnocranium CNS/
Joint
Other
Specify Other
For MRI and CT reports please select the report turnaround required
Standard (turnaround 24 hours)
Express (turnaround max. 6 hours - please note an additional surcharge will be added for weekend express)
Is this an emergency case?
Please Select
Yes - Critical Emergency
Not critical
No
Patient to be brought by: owner/clinic?
Please Select
Owner
Clinic employee
Other
Please specify if you would like us to contact the owner directly for booking?
*
Yes please contact the owner directly
No please send the information to us to confirm with the owner
Have any diagnostic tests already been performed?
Please Select
Yes
No
Diagnostic results (if available)
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Tests performed
Specific diagnostic tests required (to be run from referral centre)?
Is the patient insured?
Please Select
Yes
No
If yes, state insurance company name
Please state any further information of importance
Please verify that you are human
*
Submit
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