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Small Animal Veterinary Referral Form We are currently reviewing our Behaviour Service and are looking to increase our consultation capacity. As such, all new scheduled appointment requests will be put on to our waiting list and as soon as we identify these extra consultation slots, we will allocated additional appointment on a first come first served basis and will contact you accordingly. Thank you for your patience as we are working to improve this very popular service. Client's details Please provide the following details about the animal's owner: Client's full name Client's Address Email Address Phone No Alternative Phone No Insurance Co Personal data is stored in accordance with the UK Data Protection Act 2018, and the GDPR, however please ensure that you have informed your client that you will be submitting personal data as part of the referral. See Information and Data Processing at the RVC - a Guide for Veterinary Practices for information on your and our responsibilities to protect your client's personal data. Animal's details Please provide the following details about the animal patient being referred: Animal's Name Age Sex Male Female Neutered Yes No Species Please select... Cat Dog Other... Breed Colour Does the patient have confirmed or suspected infectious respiratory disease (e.g. Kennel cough) Yes No Does the patient have confirmed multi-drug resistant infection (e.g. wound, skin, ears, urinary tract) Yes No Does the patient have or has the patient previously had a confirmed MRSA/MRSP? Yes No Practice details Please provide the following details about the referring vet/practice: Referring Vet Practice Name Practice Address Phone No Email Referral details Please provide all the following details about your referral: Clinical Service required Behaviour Cardiology Dermatology Hydrotherapy Internal Medicine Neurology Oncology Ophthalmology Orthopaedics Pain Clinic Physiotherapy Radioactive Iodine Therapy Soft Tissue Surgery (Please select the service you wish to refer the animal to) Presenting Complaint (including when the animal was last considered normal) Please send any radiographs or other imaging in DICOM format to QMHReception@rvc.ac.uk. This is the preferred format as all patient information, alongside the date and time of image acquisition, is included within the DICOM files. If you do not send DICOM images, please send JPG but please ensure that the date of image acquisition is included. Referral Letter Full Case History Submit
