Referral Form

If this is an emergency referral, please phone 08 8313 1999 to perform a vet-to-vet handover and inform the clinic of the patients case and arrival.

To submit a referral request to the Roseworthy Veterinary Hospital, please fill in the below form or email vet.reception@adelaide.edu.au and CC afterhoursvet@adelaide.edu.au.

Referring vet information

Referring clinic name

Referring veterinarian name

Referring clinic email address

Referring clinic phone number:

Urgent?

Yes

No

Which service will you be referring to?

Is there a particular clinician you wish to refer to?

Client information

Client name

Client email

Client phone number

Will the client call us, or would you prefer the RVH contact the client?

Patient information

Patient name

Patient age or date of birth

Patient species and breed

Patient sex & desexing status

Patient vaccination status

Weight (kg)

Suspected infectious disease?

Yes

No

Patient case notes / summary

Does the patient have any behavioural concerns?

Any known allergies or alerts we should be aware of?

Please attach the patients history (Medical notes, imaging and laboratory notes)

Unlimited number of files can be uploaded to this field.
20 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

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