Refer a Hydrotherapy Case

Client Name:

Pet Name:

Client's Address:

Client Email:

Client Telephone Number:

Pet Breed:

Pet's Age:

Pet's Sex:

Male Entire
Female Entire
Male Neutered
Female Neutered

Vaccination Status*:

Insured?*:

Yes
No

Pet Weight (kg):

Vet Details

Name of Referring Practice:

Name of Referring Vet:

Practice Post Code:

Practice Telephone Number:

Practice Email:

Is the patient on any current medication? If so please list (including doses and frequency):

Reason for referral*:

Any areas of caution?*:

In your opinion, is the dog named above in a suitable state of health to undergo treatment?*:

Yes
No

Please send any radiographs or other imaging in DICOM/JPG format to longwater@taverhamvets.co.uk.

Attach Referral Letter*:

Attach Full Case History*:

Attach Laboratory Results:

If you have a file which you are unable to attach here it can be emailed to longwater@taverhamvets.co.uk

YOU MUST BE 18 YEARS OR OLDER TO SUBMIT THIS FORM.

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 Privacy Notice for information on your and our responsibilities to protect your client's personal data.

Security Question:

Select a surgery:

I have read and agreed to the privacy notice:

Refer a Hydrotherapy Case

Vet Details

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