Refer Online

Client Details

Title *

First Name *

Surname *

Address *

Postcode *

Telephone *

Mobile

Email *

Patient Details

Name *

Species *

Breed *

Weight *

Date of Birth *

Month

Day

Year

Colour

Gender and Neutering Status *

Is The Patient Insured? *

Yes

Insurance Provider

Insurance Policy Number

Is The Patient Fit For Travel? *

Yes

Before we can process your referral please complete the information below.

Has the patient been imported or travelled outside of the UK? *

Yes

If Yes, please specify the countries they have been imported from/visited *

Patient Cautions

Please Provide a Summary of Patient's Clinical History Including Duration of Complaint *

Onset (per-acute/acute/chronic); any concurrent disease; main findings on clinical examination; any tests already conducted (bloodwork, imaging); response to medication/any current relevant medication; main differential diagnoses.

Reason For Referral *

Please Note: Please provide a succinct summary of the patient’s history and their current condition. All relevant results, imaging and history must be attached along with the patient’s full medical history. Failure to provide all relevant information may result in delays to the referral process.

Documents

Patient History and Supporting Documents *

Imaging Documents

Lab Results Documents

If your documents are located on a third-party system you must first download them to your device and then upload them to this form. Accepted formats: jpg, jpeg, png, gif, pdf, doc, docx, dcm, zip (8MB maximum). To send larger attachments, or if you experience problems uploading your documents via this form, please email (8MB max per email) to referrals@valleyvets.net. Please note: If you try to submit this form and fail to complete the fields correctly, you will need to re-attach the documents before re-submitting the form a second time.

Referring Vet Details

Title *

First Name *

Surname *

Practice Name *

Address *

Postcode *

Telephone *

Email *

Other Information

Please Tell Us Why You Chose Valley Veterinary Hospital

Please Add Additional Notes Here