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Small Animal Veterinary Advice Enquiry Form FOR REFERRING VETS USE ONLY This is an advice enquiry form only; if you require an urgent referral, or urgent advice, please call 01707 666399 (option 1). This form is for the referral of cats and dogs only. For Exotics and Small Mammal advice please email exoticscamden@rvc.ac.uk. Please help us to help you. To enable us to efficiently respond to your advice enquiry, please complete the following information and submit this form to us. Please be as concise as possible, providing only the pertinent information. If we require more information, we will let you know. Please note this service is free of charge and whilst we aim to call you in a timely manner, depending on our own hospital case load, this might not be possible. If you would like to arrange a referral please contact us at 01707 666399 (and select option 2). Thank you! Clinical Service Anaesthesia Behaviour Cardiology Dermatology Hydrotherapy Internal Medicine Neurology Oncology Ophthalmology Orthopaedics Pain Clinic Physiotherapy Soft Tissue Surgery (Please select the service you wish to make the enquiry to) Has this patient ever been a patient at the QMHA? Yes No QMHA case number / reference number Your case number Specific nature of the advice required Are you considering referring this patient to the QMHA? Yes No Referral is not an option for this patient/client Animal's details Species Please select... Cat Dog Other... Breed Name Age Weight Sex Male Female Neutered Yes No Presenting Complaint (Including when the animal was last considered normal. Please keep the description brief, maximum of around six sentences, thank you) Summarised History (Please keep the description brief, maximum of around six sentences, thank you) Physical Examination (Please keep the description brief, maximum of around six sentences, thank you) Relevant Laboratory Results (Please keep the description brief, maximum of around six sentences, thank you) Medications (Please keep the description brief, maximum of around six sentences, thank you) Additionally if you would like to provide more information or photos, please upload one of the following: A single document (such as a case history) or a photo A single document containing a case history and/or other relevant notes and/or one or more photos all inserted into the document A single zip file containing multiple documents and/or photos File Upload Practice details Referring Vet Practice Name Phone No Mobile No Email Submit
