How to refer

Please fill in the online form giving as many details as possible. You can attach any patient medical history at the bottom of the form. We recommend using a PDF format.

Once you have submitted the form, someone from our team will get in touch to discuss the case, and schedule a call with your client to arrange an appointment.

In case of emergencies, or you wish to discuss a case with one of our clinicians, we recommend calling us on: 01782 649 914

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Referring Vet Practice Details

Referring Clinician Name *

Referring Vet Practice Postcode *

Referring Vet Practice Name *

Referring Vet Practice Email *

Referring Vet Practice Phone Number *

Client Information

Client Name *

Client Email *

Client Phone Number *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Patient Details

Patient Name *

Patient Species/Breed *

Patient Age *

Years and Months

Patient Sex *

Male Entire
Female Entire
Male Neutered
Female Neutered

Brief Summary of Case

Please give us a description of the case.

Contact Patient Details

Is the Pet Insured? *

Who is the pet insured with?

Service Required *

Orthopaedic
Endoscopy
Soft Tissue
Out-Patient CT
Other

If other, please provide details

Case Urgency *

Urgent
Non-Urgent

Case Description File Upload

Click or drag files to this area to upload. You can upload up to 3 files.

Please attach the appropriate case history and any additional records e.g. test results, radiographs, ECG tracings etc (Max total file size 30MB per file).

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Keele Veterinary Referrals
Garden Vets at Keele
Keele University
Staffordshire
ST5 5NU

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