If your case is an emergency, please contact the surgery BEFORE sending this form.

Failure to contact us regarding an emergency case may result in the referral not being processed urgently.

Referrals must come from a veterinary surgeon. Clients cannot directly refer their own pet. To refer an ophthalmic case to us then please complete the form below. Please include details regarding the case, any appropriate history and information about any current medications.

Please note that advice cases will be treated as advice only unless they result in an actual referral appointment being requested.

Vet Referral Form

Referring Veterinary Surgeon *

Veterinary Practice Name/Address *

Practice Phone Number *

Practice Email *

Clients Name *

First

Last

Clients Email *

Clients Phone Number *

Patients Name *

Species *

Breed *

Patient Sex *

Female
Male
Unknown

Please Indicate *

Neutered
Entire
Unknown

Is the patient insured for veterinary fees? *

Yes
No
Unknown

Preferred Clinic Location *

Pet Insurance Company (If Known)

Presenting condition (briefly explain the problem) *

Please submit a copy of the patient's clinical history: *

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Additional file (photo, lab result)

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Additional file (photo, lab result)

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.