Referral Form - Kettering Vets

This form is for veterinary surgeons to refer a case - if you are a pet owner and wish to contact us by email please click here. Please give as much detail as possible in your history and provide all diagnostic test results even if the results are normal or negative. If you need to discuss a case or require an estimate prior to referral you can contact us. Please note that we cannot give precise estimates until we have seen the pet. We will usually contact the owner directly to arrange the appointment.

DISCIPLINE TO WHICH YOU ARE REFERRING(Required)

Practice Details

VETERINARY SURGEON(Required)

PRACTICE(Required)

REFERRING PRACTICE ADDRESS(Required)

PHONE NUMBER(Required)

EMAIL OF REFERRING VETERINARY SURGEON(Required)

REASON FOR REFERRAL

DO YOU WISH TO DISCUSS THIS CASE BEFORE WE CONTACT THE OWNER?

YES

HOW WILL THIS REFERRAL BE FINANCED?

Owner Details

TITLE

FIRST NAME OR INITIAL(Required)

SURNAME(Required)

Address

Address Line 1 Address Line 2 City County Postcode

TELEPHONE NUMBER(Required)

MOBILE NUMBER(Required)

Email(Required)

Patient Details

PET NAME(Required)

SPECIES

SEX

NEUTERED

BREED

AGE

Please attach a copy of the history, including any test results below. Alternatively, you may email them to referrals@theketteringvets.com Please note we are unable to book an appointment for your client until we have received this.

ATTACH A FILE

Max. file size: 128 MB.

INSURED?

INSURANCE COMPANY (If applicable)

POLICY LIMIT (If applicable)

AMOUNT SPENT TO DATE (If applicable)