Refer A Client

If you need to refer a client urgently, please fill this form AND contact us on 01744 853 510.

Referring Vets Name*

Referring Veterinary Practice*

Practice Address*

Practice Postcode*

Practice Telephone Number*

Practice Email*

Client's Title and Full Name*

Client's Address*

Client's Town*

Client's Postcode*

Client's Mobile Number*

Client's Email*

Pets Name*

Species*

Breed*

D.O.B*

Age*

Sex*

Neutered?*

Colour*

Has the pet been abroad?*

Insurance Company Name*

Policy Number*

Department Referring to*

What is the specific problem/investigation/treatment for which you wish to refer the patient*

Please attach Full clinical history (including Blood and Lab results) and x-rays (if available)

Drop files here or

Max. file size: 50 MB.

Please contact me prior to the appointment to discuss the case.*

Do you want a receptionist at Rutland House Referrals to contact the client and make an appointment?

Please tick here if you DO NOT agree to allow Rutland House Referrals to forward your clinical history to your client’s insurance company

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