Online Referral Form
Registration Form for Routine Appointments
NB: This form should ONLY be used by Veterinary Professionals not by clients wishing to make an appointment. If you are a pet owner, either contact your vet for referral or telephone Southfields Veterinary Specialist on 01268 564664 for assistance.
The following form should be completed and accompanied by a referral letter, full clinical history, including laboratory results and radiographs (please supply normal and abnormal results). The history, test results/radiographs and a covering letter can either be uploaded using this registration form (see below) or they can be emailed separately to: [email protected] (if emailing, please include the Referred Case Registration Number which will be emailed to you once this form has been submitted).
To arrange an appointment
After you have submitted the form, our reception staff will contact either you or your client directly to arrange an appointment (depending on your contact preference indicated below).
All information submitted will be held securely and used only by Southfields Veterinary Specialist, and never passed to third parties without your express permission.
Why Sign Up?
- Speed up the submission process by auto-completing your details
- Register for Southfields information updates
- Manage your details for information updates
- Review your past referral history all in one convenient place
How to Sign Up?
- Sign up using the sign up form
- Complete this form and simply add a username and password at the end of this form
The files listed below are invalid, please resubmit the form using one of the following acceptable file formats
.pdf, .doc, .docx, .xls, .xlsx, .rtf, .txt, .jpg, .bmp, .gif, .tiff, .png, .zip
Please complete the following details:
(NB: This form should ONLY be used by Veterinary Surgeons, not by pet owners)