Referral Form

Type of Referral

Full referralPartial referral

A consultation will be done with the client to manage the procedure/concern referred for. Please select one of the below options.

The referring vet agrees for Amber Vet to manage other medical condition(s) that may arise during the consultation/course of treatment, with the client’s consent.Please contact the referring vet before managing other medical condition(s) may that arise during the consultation/course of treatment.Do not manage any other medical condition(s) unrelated to the reason for referral.

Please take note of the following points for partial referral:

A consultation will not be done with the client, unless stated below for specific procedures that require sedation/anaesthesia, in which case the consultation will be limited to assessing and discussing sedation/anaesthesia risks with the client.

A report of the diagnostic findings will be provided to the referring vet, who will discuss these findings with the client. Amber Vet will not discuss any findings with the client.

The referring vet will communicate the above to the client before the referral appointment at Amber Vet.

Referring Vet

Referring clinic

Date of Referral submission

Date

Referring Clinic Phone Number

Please enter a valid phone number.Format: 00000000.

Referring Clinic Email

example@example.com

Owner's Name

First NameLast Name

Owner's Phone Number

Please enter a valid phone number.Format: 00000000.

Owner's Email

example@example.com

Owner's Address

Street Address

Street Address Line 2

Postal / Zip Code

Pet Details

Gender

MaleFemale

Sterilised

YesNo

Clinical History

(Please include duration, clinical signs, treatments and medications, or attach clinical records)

File Upload (If Any)

(Please attach relevant medical records and case summary)

Diagnostic data accompanying referral

Laboratory (blood/urine test results)RadiographNoneOther

Referral Form

Referring Veterinary Centre

Owner's Details

Patient's Details

Reason for Referral