Village Vet Referral form - London Vet Specialists

Referring vet name

First Last

Practice location

Pet's name

First Last

Postcode of patient

Part A: Details of Referral

Please select the service required:

Please select the discipline to which you are referring?

Please describe the condition and reason for referring:

Preferred Method of Contact for scheduling appointment:

CT Scan

Dear Colleague, Thank you for referring this patient for a CT. We are able to provide a day-patient service, offering CT and image guided biopsies; the patients should be prepared for GA. The CT report will be emailed directly to you (to the email address provided). Cases needing further assessment and diagnostics (e.g. endoscopy) or surgery should be referred through Medicine or Surgery. Critical cases need to be referred through the Emergency and Critical Care service. Please note should a patient deteriorate while in our care will be transferred to the ECC service for stabilisation and possible treatment, as deemed appropriate in the best interests of the patient. Please could you answer the below questions to support your referral and so we are able to contact your client directly.

Does this patient require an onsite radiologist (for sampling or immediate interpretation)?*

Yes
No

Have you discussed the risks of sedation and sampling with this client?*

Yes
No

Main clinical signs/brief case summary:*

Main ancillary test results:*

Differential diagnosis (if any):

CT region requested and sampling required (charges per region apply, please be specific e.g. stifle, neck):*

If an orthopaedics case, is the lameness localised and to which area?

Ultrasound

Have you discussed the risks of sedation and sampling with this client?**

Yes
No

Main clinical signs/brief case summary:*

Main ancillary test results:*

Differential diagnosis (if any):

Ultrasound region requested and sampling required (e.g. thorax, abdomen):*

Preferred Method of Contact:*

Part B: Checklist of Required Information

To upload the following required information you can log in to the CIMAR system, or alternatively please send full clinical history to lvs@londonvetspecialists.vet:

Referral Letters
Full Clinical History
Laboratory Results (normal & abnormal)
Imaging, if applicable (normal & abnormal)

CAPTCHA

On submission you will be redirected to the File share CIMAR page, if you do not wish to upload the files this way please send full clinical history to lvs@londonvetspecialists.vet once you have hit submit

Referral form for Village Vet patients

Part A: Details of Referral

CT Scan

Ultrasound

Part B: Checklist of Required Information

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