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Small Animal Veterinary Referral Form Please note that electives won’t be booked in until after the 1st June (this is subject to change). Only use this form if you believe the case can wait a couple of months to be seen.If the patient requires urgent care please call us on 01707 666 399 For Exotics and Small Mammal referrals please phone 020 7387 8134. We are sorry to inform our clients and colleagues that due to unplanned staff shortages we are currently unable to accept any patients for our cardiothoracic surgery programme. If you have further queries, please contact qmhaheartsurgery@rvc.ac.uk 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 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 the following details about your referral: Clinical Service required Behaviour Cardiology Dermatology Hydrotherapy Internal Medicine Neurology Oncology Ophthalmology Orthopaedics Pain Clinic Physiotherapy Soft Tissue Surgery (Please select the service you wish to refer the animal to) Presenting Complaint (including when the animal was last considered normal) Referral Letter Full Case History Submit
