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Small Animal Veterinary Referral Form If you are referring a dog with a heart murmur under the age of 2 years old to the Cardiology service, please can you instead call 01707 666399 to discuss this If you are referring a dog that has been imported to the UK or travelled to an area where Brucella canis is considered endemic please read this information. 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 Has the patient ever travelled or been imported outside of the UK? Yes No If the patient has been imported or travelled outside of the UK, have they been tested for Brucella Canis? Yes No If yes, please state result here: 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
