PRACTICE DETAILS Veterinary Surgeon * Practice * Town * Postcode * Phone Number * Practice email address Veterinary surgeon's email address * OOH service provider OWNER DETAILS Title - Select -MrMrsMsMiss First Name * Surname * Address House name / Number Town County Postcode Telephone 1 Telephone 2 Email PATIENT DETAILS Pet Name Species * - Select -CanineFelineOther Sex - None -Male - entireFemale - enitreMale - neuteredFemale - speyed Breed DOB Insured * Yes No REFERRAL DETAILS Case summary * Please concisely outline the reasons for referral (not the entire history) - we really need this information to assess the case. Photos are very helpful for ophthalmology cases (attach below). Consultation Prices * Standard (Routine) £300 Urgent (Monday - Friday) £350 - £400 OOH Emergency (Evenings & Weekends) £470 - £590 OOH Emergency is Ophthalmology only. (Weekdays after 17:30hrs / weekends / public holidays). If your referral is an OOH Emergency, please telephone us as well on 01243 888091. Speciality required: Cardiology Internal Medicine Ophthalmology Orthopaedic Surgery Pain Management Clinic Soft Tissue Surgery Patient historyPlease attach patient history and any relevant reports, photos, radiographs etc. (FULL PATIENT HISTORY FROM BIRTH is required for us to be able to process insurance claims). Choose a file and then upload it. Repeat process for each file. Add a new file Upload Files must be less than 8 MB.Allowed file types: gif jpg jpeg png txt pdf doc docx. Is there anything that causes the patient distress? How does the patient behave when distressed? Please briefly describe the behaviour How have you managed this patient in the past? Anxiolytics Muzzle Pheromone therapy Sedation Handling techniques Other: _______ Was this management technique successful? Is this patient under the care of (please tick if appropriate): Clinical Animal Behaviourist Animal Trainer CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions. SEND
