Vet referral

Vet practice name

Vet practice address

Your Name (vet)

Surname (vet)

Email Address

Contact number

Referral details (reason for referral – please do not include the pet name here that will be added below)

OWNER DETAILS

First name

Surname

Email Address

Contact number

Claimant status
Please select an option… Employed Universal Credit Pip Unknown

Is the pet insured?
Please select an option… Yes No

PET DETAILS

Pet name

Pet age

Pet type (i.e. Dog, cat, rabbit etc)

Pet breed

Pre-existing medical conditions? If so please state, if not say ‘NO’

Have they used Save A Pet Before

Cost of total procedure

Please provide a breakdown of the costs and treatment needed

What is the agreed amount the client is paying towards treatment?

What evidence will be provided to support their claim? (ie benefits, proof of address? these will need to be sent to us prior to any support offered)

Have the clients approached other chariities, if so who? (i.e PDSA, RSPCA etc)

Is there a discount being offered by the practice to help the charity?

Has a payment plan been offered?

Has the pet been microchipped, spade or neutered? (If chipped please provide the number)

Where did you hear about us?