ChesterGates Referral Hospital - Refer a case (online)

Practice Details

Name of Referring Veterinary Surgeon:

Practice Name/Address & Postcode:

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:

Insurance Details

Insurance Company:

Policy Number:

Excess Paid:

Yes No £

Have you submitted a claim?:

Yes No 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:

Emergency Urgent Routine

Speciality Required:

NEUROLOGY
MRI SCANNING
SPINAL SURGERY
NEUROSURGERY
ORTHOPAEDICS
SOFT TISSUE SURGERY
CARDIOLOGY
RADIOLOGY
ULTRASONOGRAPHY
INTERNAL MEDICINE
CT SCANNING
PHYSIOTHERAPY
HYDROTHERAPY
DERMATOLOGY
ICU
OUT OF HOURS SERVICE
DIAGNOSTIC IMAGING READING SERVICE

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:

No additional patient's history sent;
I will be sending my patient's history under separate cover by e-mail;
I will be sending my patient's history under separate cover by fax;
I will be sending my patient's history under separate cover by post

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