Refer a case (online)

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Please telephone us on 01244 853 823 if you wish to speak to a Specialist. Please make your Clients aware that their pet may need to stay with us for the whole day or overnight.

Practice Details

Name of Referring Veterinary Surgeon: 
Practice Name/Address & Postcode: 
Are you a CVS practice?
Practice telephone: 
Fax:
Email: 
Name of 1st Opionion Vet (if you are Emergency Vets):
 
Please note: Reports will be emailed to your Practice where an email address is given.
 

Client Details

Owner name (including Title):
Owner address: 
Owner e-mail: 
Owner Tel(Home):
Owner Tel(Mobile):
 

Patient Information

Animal name: 
Species: 
Breed: 
Date of Birth (dd/mm/yyyy):
Sex (M / F / MN / FN):
Weight:
Microchip No:
Colour:
Last Booster Date (dd/mm/yyyy):
HPC Start date (dd/mm/yyyy):
HPC scheme number:
 

Insurance Details

Insurance Company:
Policy Number:
Excess Paid:   £ 
Have you submitted a claim?:   If YES please enter date (dd/mm/yyyy); 
   Please tick here if you DO NOT agree to allow ChesterGates Referral Hospital to forward your clinical history to your client’s insurance company.
   

Case Details

Is this case:
Speciality Required: 







 
Brief description of problem:
If the case is an emergency - PLEASE also phone one of our service representatives for immediate assistance.

PLEASE ATTACH 12 MONTHS' CLINICAL HISTORY INCLUDING HAEMATOLOGY, BIOCHEMISTRY AND ELECTROLYTE RESULTS. IF POSTING PLEASE ENSURE RADIOGRAPHS ARE NAMED OR WE WILL BE UNABLE TO RETURN THEM

Please check one of the following:  



   
Once you have fully completed this form please click the 'Refer Case' button below.

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