Your normal vet needs to submit a referral request for you. Referring veterinary surgeon: Surgeon titleMrMrsMissMs Surgeon Name Practice name Practice address Practice Postcode Practice Phone Practice Email Owner's details: Owner titleMrMrsMissMs Owner Name Owner address Owner Postcode Owner Home Phone Owner Mobile Phone Owner Email Patient's details Patient's name SpeciesCatDogOther Breed SexMaleFemale Neutered?YesNoUnknown Age Insured?YesNoNot Known Details of referral Type of referralRoutineUrgent Please fill in further details below depending on which service you require Cardio-respiratory referral Reason for referral:MurmurArrhythmiaCollapse / weaknessCoughDyspnoeaNasal disease Outpatient ultrasound Area(s) to be scanned:AbdomenSmall parts (eye/swelling/wound)Pregnancy diagnosis Outpatient CT Area(s) to be scanned:Abdomen/PelvisHead (including dental)Spine: cervicalSpine: thoracolumbarForelimb: shoulderForelimb: elbowForelimb: carpi/footHindlimb: pelvis/hipHindlimb: stiflesHindlimb: tarsi/foot Please note, patients requiring thoracic CT should be seen via the cardio-respiratory service rather than simply being booked for a CT, so please fill in the options for cario-respiratory referral above Laparoscopy Surgical procedure:OvariectomyCryptorchid castrateLiver biopsyOther (please specify below) For other laparoscopic procedures, please call us on 01273 540430 or email referrals@new-priory.com to discuss the case first. Clinical History Upload Please send full history including radiographs and labarotory results. File upload 01 File upload 02 File upload 03 Upload limit per file is 1mb Additional comments
