Online Referral Form

Hello, Welcome to Blaise Referral Hospital

For routine referrals, please complete the online form below and we will liaise with our teams and come back with suitable appointment options and an estimate of treatment.

SHOULD YOU NEED US URGENTLY, please call 0121 238 2000 and speak to one of our ECC clinicians.

We look forward to working with you and your teams and meeting your clients and their pets.

Pet owners are reminded that referrals must come from a vet. Submissions from pet owners will not be processed.

Client Details

Client Name:

Pet Name:

Client Email:

Client Telephone Number:

Vet Details

Name of Referring Practice:

Practice Email:

Practice Telephone Number:

Name of Referring Vet:

Referral Details

Please select which department would you like to refer to? :

Has this case been discussed with a specific clinician?:

If answered yes, please state their name:

Please can you briefly write what diagnostic testing you have done such as radiographs or bloods (This assists us in requesting all relevant history) *Required:

Could you give us a few details about the referral you are making? *Required:

Attachments

Please attach the appropriate case history and any additional records e.g. test results, radiographs, ECG tracings etc (Max total file size 8MB).

Attach Animal History*:

Attach Animal History:

Pet Details

*All fields are mandatory*

Pet's Sex:

Pet Species:

Pet Breed:

Pet's Age:

Financial Details

*All fields are mandatory*

Is the pet insured?:

Insurance Company Name:

Policy Number:

Policyholder Name:

Please advise us where you heard about Blaise?:

Please advise us why you chose to refer this patient to Blaise?:

Security Question:

Select a surgery:

I have read and agreed to the privacy notice:

Online Referral Form

Hello, Welcome to Blaise Referral Hospital

Client Details

Vet Details

Referral Details

Attachments

Pet Details

Financial Details

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