Veterinary Professionals Refer A Case Veterinary Professionals Overview Outpatient Imaging Service Veterinary Professionals Referral Feedback Form CPD at North Downs Insights Refer A Case My Referral History My Referral History 1Owner Details2Patient Details3Referral Details4Clinical History5About You Owner's Name(Required) Mr.Mrs.MissMsMxDrProfOther Title Owner's First Name Owner's Last Name Owner's Telephone Number(Required)Owner's Telephone Number 2Owner's Mobile NumberIf multiple owners or an organisation, please add detailsOwner's Email Address(Required) Enter Email Confirm Email In the event of any queries, and for clients preferring to book their appointment with us directly, please indicate the owner's preferred contact method(Required) Telephone 1 Telephone 2 Mobile Number Owner's Address(Required) Address Line 1 Address Line 2 City ZIP / Postal Code Pet's Name(Required)Species(Required)DogCatGender(Required)MaleMale/NFemaleFemale/NBreed(Required)Weight (kg)(Required)Enter 'unknown' if this is the caseDate of Birth(Required)If unknown, enter pet's approximate ageHas this patient been referred to NDSR previously?(Required) Yes No Urgency(Required) Routine Urgent Emergency Please select the primary discipline to which you are referring(Required)CardiologyDentistryDermatologyInternal MedicineNeurology/Spinal Surgery (inc. MRI)OncologyOphthalmologyOrthopaedicsPain ManagementSoft Tissue SurgeryPlease indicate contact preference for North Downs Specialist Referrals making this appointment(Required)Contact you first (referring Veterinary Surgeon)Contact client directlyFor complex issues where multiple disciplines may be involved, please enter details belowInsured for vets fees?(Required) No Yes Please describe the condition and the reason for referring(Required) Please upload a copy of the clinical history including blood tests, urinalysis, cytology or histopathology results and radiographs. A brief referral letter outlining the nature of the referral is much appreciated and can help increase the efficiency of case throughput and follow-up reporting. Clinical history and previously performed diagnostics (please include normal as well as abnormal results) may also be emailed to enquiries@ndsr.co.uk – please tick the relevant box on the form below and remember to quote the case referral reference number (the referral reference number will be shown and emailed to you automatically once this form is submitted).Upload Case AttachmentsWe accept large files in the following formats: .pdf, .doc, .docx, .xls, .xlsx, .rtf, .txt, .jpg, .bmp, .gif, .tiff, .png, .dcm, .eml, .zipClinical History and Brief Referral Letter Drop files here or Select files Max. file size: 60 MB. Radiographs/CT/ MRI/Ultrasound Drop files here or Select files Max. file size: 60 MB. Blood Tests/Urinalysis/ Cytology/Histopathology Drop files here or Select files Max. file size: 60 MB. Or email/fax I intend to email I intend to fax N/A - files attached above Please remember to quote the case referral reference number. Clinical history and previously performed diagnostics may be emailed to: enquiries@ndsr.co.ukPlease remember to quote the case referral reference number. Clinical history and previously performed diagnostics may be faxed to: 01883 740154. Name(Required) Mr.Mrs.MissMs.Mx.Dr.Prof.Other Title First Last Practice Name(Required)Locum? Please tick if you are a Locum Practice Telephone Number 1(Required)Practice Telephone Number 2Other Telephone NumberMobile Telephone NumberYour Email Address(Required) Surgeon's preferred contact methodIn the event of any queries, or if you have indicated below that you wish to book the appointment on behalf of your client, please specify your preferred contact method for arranging this referral: Practice Telephone Number 1 Practice Telephone Number 2 Other Telephone Number Mobile Telephone Number Practice Address(Required) Address Line 1 Address Line 2 City ZIP / Postal Code
