Refer a Case

Type of Referral:

Non-urgent Appointment (Next Available Appointment)
Urgent Appointment (Within 5 Working Days)

Client Details

Client Name:

Client's Address:

Client Email:

Client Telephone Number:

Alternative Phone Number:

Insurance Company Name:

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.

Patient Details

Pet Name:

Pet's Age:

Pet Weight (kg):

Pet's Sex:

Male Entire
Female Entire
Male Neutered
Female Neutered

Temperament - is care required when examining / handling this patient?:

Yes
No

Pet Species:

Feline
Canine

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 or has the patient previously had a confirmed MRSA/MRSP?:

Yes
No

Has the patient ever travelled or been imported outside of the UK?:

Yes
No

If yes, please state when and what country here:

If the patient has been imported or travelled outside of the UK, have they been tested for Brucella Canis?:

Yes
No

** Please note we do not accept imported patients that have not been Brucella tested or Brucella positive animals**

Vet Details

Name of Referring Vet:

Name of Referring Practice:

Practice Post Code:

Practice Telephone Number:

Practice Alternative Number:

Practice Email:

Referral Details

Presenting complaint (Please detail current clinical signs and concerns):

How long have these signs been present?:

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

Checklist to share with Taverham Veterinary Hospital

It is essential we receive this information prior to arranging the appointment with the client. If not received this could potentially delay the patient being seen.

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

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

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Refer a Case

PLEASE NOTE THIS FORM IS FOR REFERRING VETS USE ONLY

Client Details

Patient Details

Vet Details

Referral Details

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