Submit Case Report

Do you wish to submit this report?

Submit Case Report

Prior to submitting please preview the report using the Save and Preview button.

Use the browser back button to return.

Cancel Case Report Assignment

Are you sure you wish to cancel your assignment to report on this case – all inputted data will be lost!

Delete Case

Do you want to delete this case?

Southfields

Your login session has timed out.
Please login below.

By using this website, you agree to our use of cookies to enhance your experience.

Formerly VRCC

+44 (0)1268 564664

24 hour veterinary and nursing care

+44 (0)1268 564664

24 hour veterinary and nursing care

This site is optimised for modern web browsers, and does not fully support your version of Internet Explorer, some sections of the website may not work correctly such as web forms

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.

Already signed up?

Login

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)

FORM CONTAINS ERRORS!

Please review, correct and resubmit.

Emergency, Urgent and Out-of-Hours Referrals

Please DO NOT use this form for emergency, urgent and out-of-hours referrals, but instead call reception on 01268 564664 to speak to a member of staff.

Referring Veterinary
Surgeon's Details (About You)

* Denotes a required field

In the event of any queries, or if you have indicated below that you wish to book the appointment on behalf of your client, please specify your preferred contact method for arranging this referral:

Email address already taken

Your email address does not match

Saving your details

45% Complete

Owner's Details

Please ensure that telephone numbers are current and accurate and include an STD code

In the event of any queries, and for clients preferring to book their appointment with us directly, please indicate the owner's preferred contact method:

Patient's Details

OR

 Years    Months

Has this patient been referred to Southfields previously?

Details of Referral

Processing your registration details

45% Complete

Clinical History

Clinical history and previously performed diagnostics (please include normal as well as abnormal results)

Please upload a copy of the clinical history including blood tests, urinalysis, cytology or histopathology results and radiographs using the upload button below. A brief referral letter outlining the nature of the referral is much appreciated and can help increase the efficiency of case throughput and follow-up reporting.

For each file please click on the 'Add or Drag Attachments Here' button.

Further information can be emailed to [email protected] remembering to quote the case referral reference number in all correspondence (the referral reference number will be emailed to you automatically once this form is submitted).

Note: We accept files in the following formats: .pdf, .doc, .docx, .xls, .xlsx, .rtf, .txt, .jpg, .bmp, .gif, .tiff, .png, .dcm, .eml, .zip

Attachment Checklist

Sure you don't want to sign up?

Only a username and password required

Your Password

  • Must be different from your Username
  • Must contain at least 8 characters including one capital letter and number
  • May include the following characters:
    % & _ ? # = -

Username already taken

Please type a password with at least 8 characters, 1 uppercase letter and 1 number

Password does not match

Attachment review
prior to submiting:

Please review the following attachment/s:

Processing your registration details

45% Complete