Referral Appointment Request Form Current Start Referring Vet's details Pet's details Service requested Final check Preview Complete Start OWNER'S DETAILS Has the client attended the Dick Vet hospital before? Yes No Don't know Title Title - Select -MrMrsMissMsMxDrBaronessBaronCanonBrotherDameFatherNurseLadyLordMajorProfessorRabbiReverendOther... Enter other… First name Surname Address Postcode Preferred contact number Owner's email address Referring Vet's details REFERRING VETERINARY SURGEON'S DETAILS Title Title - Select -MrMrsMissMsMxDrBaronessBaronCanonBrotherDameFatherNurseLadyLordMajorProfessorRabbiReverendOther... Enter other… Name Has the client been advised of typical referral fees and that the responsibility for payment lies with him/her? Yes No Please forward on appropriate case history. I have provided the client with the following estimate of fees for referral services: £ Case number (if known) Practice name and address Postcode Contact number Fax number Email address Is the Primary vet different to the referring vet? Yes No Don't Know Primary Vet's Address Primary Vet's email address Pet's details Pet's name Pet's age Sex - None -MFMNFN Breed Has the pet attended the Dick Vet hospital before? Yes No Don't know Is the pet originally from outside of the UK? Yes No Has it been tested for Brucella Canis? Yes No NB if not tested, please perform a test as advised by the APHA BEFORE referral. If an animal is from abroad and not tested, we reserve the right to refuse referral.Brucella Canis Update Species Behavioural challenges or special measures required Please inform us of any behavioural challenges or special measures required when dealing with this patient (e.g. difficulties performing a physical examination, use of muzzle or specific handling/restraint, behavioural medication used etc.): Start date of condition/first signs noticed? Has the pet ever shown similar signs/symptoms in the past? Yes No If referring for Medicine or Dermatology have you previously submitted an advice request for this patient? Yes No is the client insured? Yes No Don't know Name of insurance company (if known) Policy number Service requested please choose one option from the list Behaviour Canine Internal Medicine Cardiology Dermatology Emergency and Critical care (Please also alert us by phone) Exotics Feline Internal Medicine Neurology Oncology Ophthalmology Orthopaedic Surgery Repair Clinic (physiotherapy/hydrotherapy) Soft Tissue Surgery Not sure Presenting complaint If you are referring a dog or cat with a gastrointestinal problem to Internal Medicine, do you suspect this animal to have PLE or GI lymphoma or has the animal lost a significant amount of weight? (this will help us anticipate which tests we will likely need to pre-book for the patient). Yes No For emergencies within normal working hours, please phone 0131 650 7650 Please select Routine Priority Final check Have you sent additional relevant case records? (eg radiographs, ECG tracings etc) Yes No by what method? Sent by email Client bringing to appointment For emergencies within normal working hours, please phone 0131 650 7650 and submit this form as soon as possible following the call. If you wish to make an emergency referral outwith normal office hours (Monday to Friday, 8.30am to 5:30pm), please contact our emergency service on 0131 650 7883. You should still submit this form and email the history, lab results, xrays etc to HFSAreception@ed.ac.uk I consent to the University processing the information I provide. The information you provide will only be used to manage your pet record and provide treatment as necessary. We retain your data for 10 years after our last contact with your animal. This article was published on 2024-09-02
