Download Overnight patient transfer form

Contact Us:
Phone: 0141 330 5848
Accounts: 0141 330 5848 Option 2
Fax: 0141 330 3663
Out of Office Hours email address:
[email protected].
FIRST OPINION OVERNIGHT PATIENT CARE REQUEST
Please phone to discuss the case prior to transfer:
Before 1800
After 1800
0141 330 5848
0845 850 2080
(free to call)
PRACTICE DETAILS
VETERINARY
SURGEON
PRACTICE NAME
PHONE NUMBER
FAX NUMBER
CLIENT DETAILS
NAME
ADDRESS
PHONE NUMBER
PET DETAILS
NAME
RECENT MEDICATIONS
AGE
BREED
DOSE
SEX
FREQUENCY
M/MN/F/FN
TIME LAST GIVEN
School of Veterinary Medicine, University of Glasgow, 464 Bearsden Road, Glasgow, G61 1QH
The University of Glasgow, charity number SC004401
Contact Us:
Phone: 0141 330 5848
Accounts: 0141 330 5848 Option 2
Fax: 0141 330 3663
Out of Office Hours email address:
[email protected].
PURPOSE OF OVERNIGHT
CARE
Please include: A relevant history with recent blood work. This allows us to care for the patient to
the best of our ability and avoid unnecessary repetition of diagnostic procedures.
A transfer service to our clinic can be provided by PAWS 0782 801 8777. If the patient is being
transferred without the owner please sign and date below on their behalf giving permission for
treatment. The signatory is responsible for the costs incurred.
Please indicate how the patient will be transferred back to your practice:
Owner collection
0900-1000
1000-1100
Ambulance transfer
Please tick if we are required to book this
The client will be asked to settle their account on collection of their pet. Direct claims can be
arranged for insured animals with accounts over £300. For accounts under £300, we kindly request
that insured clients pay the full balance on collection.
Alternatively, please tick the box below if you wish the practice to be invoiced for the overnight care.
Invoices must be settled within 14 days.
SIGNATURE: ……………………………………………………………………………………………………….
PRINT NAME: ………………………………………………………………………………………………………
QUALIFICATIONS: ……………………………………………………………………………………………….
DATE: ………………………………………………………………………………………………………………….
School of Veterinary Medicine, University of Glasgow, 464 Bearsden Road, Glasgow, G61 1QH
The University of Glasgow, charity number SC004401