Make a Referral - Fitzpatrick Referrals

Requirements

Referral service*

Orthopaedics
Neurology
Cardiology
Rehabilitation

Select referral service first to see available urgency options.

Please indicate urgency*

For EMERGENCY or URGENT cases please call 01483 423761 to ensure your referral is seen to as a priority. Without an accompanying call, there may be a delay in appropriate treatment.

For EMERGENCY or URGENT cases please call 01483 668100 to ensure your referral is seen to as a priority. Without an accompanying call, there may be a delay in appropriate treatment.

Client details

Title*

First name*

Surname*

Address*

Postcode*

Telephone*

Mobile

Email

Patient details

Name*

Species*

Breed*

Date of birth*

Colour

Gender & neutering status*

Insured?

Patient cautions

Behavioural / handling notes

Does the patient have an active infection?*

E.g. Wound, skin, ears, urinary

Has the patient had MRSA/MRSP?*

Has the patient travelled outside UK?*

Or been imported

Is the patient lame?

Which limb(s)?*

Is the patient ambulatory?

Can the patient bear weight on affected leg(s) without support?

When supporting the patient’s weight can you see any movement in leg(s)?

Does the patient have deep pain sensation?

Are there any signs of cranial nerve or brain involvement?*

If yes, please specify these findings:

Referral

Please include a case summary outlining: the reason for referral; the complaint/presumed diagnosis; clinical signs and their onset, progression and duration; treatment/medication trialled or ongoing and its effects; any pre-existing conditions; and expectation of visit. Without a case summary, there may be a delay triaging your case.

Reason for referral & case summary*

For Rehabilitation referrals, please specify whether for physiotherapy, hydrotherapy or both.

Does the patient have any other conditions currently requiring treatment and/or regular monitoring?*

If yes, please list:

Documents

Please provide all relevant clinical history, results, reports and diagnostic imaging with your referral, including those from other referral centres if the patient has been seen elsewhere.

Please indicate which documents and diagnostics are available to support your referral and upload them below

Patient history & supporting documents

Drop files here or

Accepted file types: png, pdf, jpg, jpeg, doc, docx, dcm, gif, zip, Max. file size: 20 MB, Max. files: 12.

Files on a 3rd party/cloud system must be downloaded to your current device to upload them to this form.

There is a limit of 12 files / 20MB in total for all uploaded files.

Send larger attachments (videos / imaging / CT / MRI) via WeTransfer.com or Dropbox to [email protected].

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Supporting documents*

Accepted file types: png, pdf, jpg, doc, docx, dcm, gif, zip, Max. file size: 100 MB.

Please attach supporting documents. If the documents you need to upload are on a third-party system, you must download them to your current device to be able to upload them to this form. Accepted formats: png, pdf, jpg, doc, docx, dcm, gif, zip (14MB maximum). To send larger attachments, please email (14MB max per email) to [email protected] (Eashing) or [email protected] (Guildford).

Referring vet details

Title*

First name*

Surname*

Practice name*

Address*

Postcode*

Telephone*

Hidden

Fax

Email*

Save your details for next time?

Not registered yet? Save your details for a quicker referral next time. You will receive an email to activate your account. In a hurry? Select 'no' to continue the referral.

Save your details

Yes
No

Email*

Email Confirm email

Password*

Enter password Confirm password

Strength indicator

Other information

Seen/referred by another referral practice?*

Has the patient been seen/referred by another referral practice prior to this referral?

Name of other referral practice

Please ensure all referral reports and imaging (DICOM /JPG) is collated and attached with this referral request.

Please tell us why you chose Fitzpatrick Referrals

Please add additional notes here

Fitzpatrick Referrals is committed to protecting your data and privacy. To understand how we will store and use your data please see our privacy policy.

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Refer online

Emergency or urgent cases: please call 01483 423761

Start the referral

Requirements

Client details

Patient details

Referral

Documents

Referring vet details

Save your details for next time?

Other information

You will receive a confirmation email that your referral form has been successfully received. If you do not receive this or experience an issue with the form, please call us or email [email protected]

Refer online

Emergency or urgent cases: please call 01483 423761

Start the referral

Sign in to your account

Register for an account

Save time when referring patients

Save time now

Requirements

Client details

Patient details

Referral

Documents

Referring vet details

Save your details for next time?

Other information

You will receive a confirmation email that your referral form has been successfully received. If you do not receive this or experience an issue with the form, please call us or email [email protected]