Refer a case

Practice Details

If your referral is of an urgent nature, please contact the practice directly on 01780 763180 and ask to speak to a member of the referrals team:

Urgent
Non Urgent

Discipline required:

Cardiology
Internal Medicine
Diagnostic Imaging

Veterinary Surgeon*:

Practice*:

Referring practice address*:

Phone Number*:

Email*:

Reason for referral (please give brief details of why you wish to refer this case)*:

Do you wish to discuss this case before we contact the owner?:

YesNo

How will this referral be financed?:

Patient is insuredClient self funding

Owner Details

Title:

First Name or Initial*:

Surname*:

Address Line 1:

Address Line 2:

Address Line 3:

City:

County:

Postcode:

Telephone Number*:

Mobile Number*:

Email Address:

Patient Details

Pet Name*:

Species:

Sex:

Neutered:

Yes
No

Breed:

Age:

Further Information

Please confirm how you will send further patient information ie referral letter, full patient history, lab results/xrays.:

Vet to post
Vet to email separately (referrals@stamfordvets.co.uk)
Owner to bring to appointment (PLEASE SEND ANY DICOM IMAGES WITH CLIENT)

How would you like to receive your report?:

Email
Post

Attach a File:

Insurance Details

Insured?:

Insurance Company:

Policy Limit:

Amount spent to date:

Security Question:

Select a surgery:

I have read and agreed to the privacy notice: