Refer a case - London Vet Specialists

Referral Type*

Estimate Requests
Referral Requests
Outpatient Imaging Requests

Estimate Request:

Please select the discipline to which you require an Estimate?*

Cardiology
CT Scan
Dermatology
Internal Medicine
Oncological Surgery
Opthalmology
Radiographs
Soft Tissue Surgery
Ultrasound

Referral Request:

Please select the discipline to which you require an referral?*

Cardiology
Dermatology
Internal Medicine
Oncological Surgery
Opthalmology
Soft Tissue Surgery

If you require a multidisciplinary referral, please detail what services you require here

Outpatient Imaging Request:

Thank you for considering sending your patient through the London Vet Specialists Outpatient Imaging Service. Please note that as an outpatient, the pet remains with you as their primary clinician. Results (e.g. imaging reports, cytology, and urinalysis) will need to be reported to the client by your own practice staff. These will be forwarded to you as they become available. We aim to have the imaging report available within 3 working days, and results from samples taken will be subject to the usual timescales of external laboratories varying with the complexity of the sample.

Please select the discipline to which you require an referral?*

CT Scan
Radiographs
Ultrasound

If you require a multidisciplinary referral, please detail what services you require here

Patient Details

Name*

Species*

Breed*

Gender*

Age*

Body Weight*

Please provide a brief synopsis of the patient history and procedures required*

Has the patient ever travel abroad / was the patient acquired from overseas?*

Yes
No

Is the patient stable and fit for transport to our hospital?*

Yes
No

Have you examined the patient within the past two weeks?*

Yes
No

Please upload all relevant patient record files and images.

Max. file size: 8 MB.

UPLOAD THE FULL MEDICAL HISTORY HERE AND EMAIL ANY FILES GREATER THAN 8MB TO OUR RECEPTION TEAM: [email protected]

Practice Details

Referring Veterinary Surgeon*

Practice Name*

Address*

Preferred Telephone Number*

Clinician's Telephone Number*

Email*

Client Details

Name*

Owner's full address*

Owner's telephone number*

Owner's email address*

Owner's insurance company*

Please confirm that the client has given consent for the handling of their personal data and for London Vet Specialists to make contact.*

Have costs been discussed with the client?*

Yes
No

Is the patient insured?*

Yes
No

What specific questions and findings do you hope to answer from the out-patient imaging referral?*

Is the client aware of the risks and consents to all of the following: Sedation, General Anaesthesia, Sampling?*

Yes
No

Has this patient had any imaging studies performed previously?*

Yes
No

(Please email findings within clinical history)

Imaging Region*

Abdomen
Thorax
Head / Neck
Musculoskeletal (Please specify)
Multiregional (Please specify)
Other (Please specify)

Please Specify

Cystocentesis*

Yes
No

Ultrasound Guided FNA’s*

Yes
No

Have you discussed the risks of contrast administration to include: Anaphylaxis, Renal Injury or Fluid Overload*

Yes
No

Preferred method of contact for scheduling the referral*

Contact Client Directly
Contact Referring Vet Practice

Permissions

London Vet Specialists is part of Linnaeus Veterinary Limited. We will not share this information with other companies for their marketing purposes. For more details on how we use your information please see our privacy policy. We would like to send you our newsletters, contact you about promotions and CPD events which may be relevant to you by post, email and SMS. If you agree to being contacted in this way please tick the relevant boxes;

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PHONE

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