Refer a case

Are You Requesting Advice Or An Appointment?*

Advice
Appointment

Response Time Required*

Urgent (appointment within 1-2 working days)
Routine (within a week of request)

Presenting complaint and objective of referral*

Veterinary Surgeon*

Practice*

City*

Postcode*

Phone Number*

Email*

Fax

Owner Name*

Address

Telephone Number*

Mobile Number*

Pet Name*

Sex *

Male (entire)
Female (entire)
Male (neutered)
Female (neutered)

Species / Breed*

Age*

Colour

Temperament

Additional Information (up to 30mb per upload)

Attach a File

Is the pet insured?

Insurance Company Name

Policy Number

Policy Holder Name

Would you like to be advised when appointment is booked?

Yes
No

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