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Small Animal Veterinary Referral Form 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 (24 January 2020). If you have further queries, please contact qmhaheartsurgery@rvc.ac.uk Please note that during the temporary closure of our Oncology Service we are unable to respond to Oncology advice enquiries. Apologies for any inconvenience. Client's details Please provide the following details about the animal's owner: Client's full name Client's 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 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
