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High quality veterinary care in a professional and caring environment

Veterinary Referral Form

* denotes required fields

Please select service required:
 Dermatology Ophthalmology Cardiology Dental

Select Practice*

Referring Veterinary Surgeon



Title and Name* :
Qualifications:
Phone Number*:
Email*:
Fax: Number*:
Referring Practice* :
Street* :
Town*:
Postcode*

Preferred contact for reports:
 post email fax

Owner's Details

Name (title, initial and surname):
Street:
Town:
Postcode:
Home Phone Number*:
Mobile Number*:

Patient Details



Name:
Age:
Sex:  male female neutered
Species:
Breed:
Insured ?  yes no
Name of Insurance Company:

Brief History/Signs:

Recent Medication:

Investigations to date:

Suspected diagnosis:

Advice needed before we contact client?
 yes no

Security Check
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Lanes Vets Limited is registered by The Royal College of Veterinary Surgeons. The RCVS register veterinary surgeons and veterinary nurses to practise in the UK, and regulate their educational, ethical and clinical standards.