Referral form for Village Vet patients Referring vet name First Last Practice location Pet's name First Last Postcode of patient Is the pet up to date with vaccinations and has it been micro-chipped?*Is the pet up to date with vaccinations and has it been micro-chipped?YesNoUnknownHave you examined the pet that you are referring in the last 2 weeks?*Have you examined the pet that you are referring in the last 2 weeks?YesNoPart A: Details of ReferralPlease select the service required:Referral of CaseEstimate RequestSubmission of additional information relating to ongoing casePlease select the discipline to which you are referring? Dermatology CT Scan Internal Medicine Oncology - Medicine Oncology - Surgical Soft Tissue Surgery Ultrasound Cardiology Please describe the condition and reason for referring:Preferred Method of Contact for scheduling appointment:Contact Clinician OnlyContact Client DirectlyCT ScanDear 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? UltrasoundHave 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:*Contact Clinician OnlyContact Client DirectlyPart B: Checklist of Required InformationTo upload the following required information you can log in to the CIMAR system, or alternatively please send full clinical history to [email protected]: Referral Letters Full Clinical History Laboratory Results (normal & abnormal) Imaging, if applicable (normal & abnormal) CAPTCHAOn 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 [email protected] once you have hit submit
