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Referral Forms

Name: Willow Veterinary Clinic Ltd
Address: Werrington, Stoke-on-Trent, Staffordshire, ST9 0JU
Telephone: 01782 302669

Referring vets - please fill out one of the online referral forms below, (underneath each online form there is a downloadable form if required).

Referring pet owners - please contact us directly so we can arrange an appointment.

CT Referral Form Ophthalmology Referral Form General Surgery Referral Form Medical Referral Form

We are always happy to take on referrals from vets or owners directly. We like to work with our local vets to provide supporting services such as our outpatient CT referral service.

For more information on our Specialist internal medicine referrals please click here

For more information about the skills and expertise of our referral team please click here

CT Referral Form

Practice Name / Referring Vet*

Practice Address*

Practice / Vet Email Address*

Practice / Vet Contact Details*

Patient Details*

History Leading To Referral*

Sedation / Anaethesia Comments? Health Problems?*

Insurance Company / Policy Number*

Investigation Area Required (Single/Multiple Areas?)*

VETCT Report Requested*

Yes

Report Priority*

2 - 3 Days

Urgent (24HRS)

Questions For Radiologist To Answer *

Upload Patient History*

No file selected

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Downloadable CT Referral Form

Ophthalmology Referral Form

Practice Name / Referring Vet*

Practice Address*

Practice / Vet Email Address*

Practice / Vet Contact Details*

Patient Details*

General Health*

Current Medication*

Eye History*

Present Eye Problem*

Insurance Company / Policy Number / Limit If Known*

Upload Patient History*

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Downloadable Ophthalmology Referral Form

General Surgery Referral Form

Service Required*

Orthopaedic

Soft Tissue

Neurosurgery

Medicine

Exotics

Practice Name / Referring Vet*

Practice Address*

Practice / Vet Email Address*

Practice / Vet Contact Details*

Patient Details*

General Health*

Current Medication*

Relevant History*

Present Problem*

Insurance Company / Policy Number / Limit If Known*

Upload Patient History*

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Downloadable General Surgery Referral Form

Medical Referral Form

Name Of Referring Vet*

Name Of Practice*

Address Of Practice*

Referring Vet Contact Number*

Referring Vet Email Address*

Client First Name*

Client Last Name*

Client Address*

Client Mobile Number*

Pet's Name*

Species*

Breed*

Sex*

Male

Female

Neutered*

Yes

Age*

Is Pet Insured*

Yes

Insurance Company / Policy Number*

Details Of Provisional Diagnosis / Condition*

Upload Patient History*

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Downloadable Medical Referral Form

Please email the completed form, along with any patient history, to referrals@willowsvets.co.uk

Endon Practice

385 Leek Road

Endon

Stoke-on-Trent

Staffordshire

ST9 9BA

 01782 503166

Willow Veterinary Clinic

50 Washerwall Lane

Werrington

Stoke-on-Trent

Staffordshire

ST9 0JU

 01782 302669

Tunstall Practice

Unit 1 Scotia Road Business Park

Fitzgerald Way

Burslem

Stoke-on-Trent

Staffordshire

ST6 4HN

 01782 826738

Links

Proudly Taking Care of Pets across Stoke-on-Trent

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