Standard Referral Form

Referring Vets: Please advise your clients that it is Earlswood’s policy not to accept payment directly from insurers for referral clients. Bills are to be settled in full on pet’s discharge.

All clients will be expected to pay a £175 deposit following first consultation with a £25 admin fee for direct claim completion (for referral clients meeting criteria).

Insured clients should bring their policy documentation and a signed claim form with them to the first consultation which we will complete and forward to their respective insurance company for reimbursement directly to the client.

To facilitate the clients prompt reimbursement from their insurer, referring vets need to send in their own insurance claim form promptly. Insurance companies are refusing to pay ongoing referral claims until primary form from own vets has been received.

Practice Details

Referring Vet*

Referring Practice*

Practice Address Line 1*

Practice Address Line 2

Practice City*

Practice Postcode*

Practice Email*

Practice Telephone Number*

Practice Fax 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

Surgery Contact

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Standard Referral Form

Practice Details

Client Details

Patient Details

Patient History

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