Online Referral Form

To be completed by the referring Veterinary Surgeon.

Please ensure to specify the areas requiring treatment (e.g. right stifle, left carpus, etc.) and any other medications or therapies the pet is receiving.

Please advise all clients that payment will be due at the time of treatment.

We will discuss the details of the available packages and relevant fees with the client when booking the first appointment.

Clients with pet insurance should check with their insurer whether laser therapy will be covered under their policy. Please remind them to bring a copy of their policy documents and a signed claim form with them to their first appointment. Forms will be completed to reimburse the client, we cannot facilitate direct claims for laser therapy at this time.

Practice Details

Referring Vet*

Referring Practice*

Practice Address Line 1*

Practice Address Line 2

Practice City*

Practice Postcode*

Practice Email*

Practice Telephone Number*

Client Details

Client Title*

Client First Name*

Client Surname*

Client Address Line 1*

Client Address Line 2

Client City*

Client Postcode*

Client Contact Number*

Patient Details

Patient Name*

Patient Species*

Patient Breed*

Patient Age*

Patient Sex*

Insurance Company*

Insurance Claim Diagnosis*

Patient History

Date of Onset of Clinical Signs*

Presenting Signs*

Clinical Exam details & relevant test results*

Attach Patient History

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