Dermatology Referral Form For routine referrals please complete the form below and attach a FULL clinical history and any laboratory results. For URGENT referrals please contact the surgery directly on 0191 410 9674. Please enable JavaScript in your browser to complete this form.Referring Veterinary Surgeon Details Referring Veterinary Surgeon *Referring Veterinary Practice *Practice Address *Telephone *Email address for referral reports *Client Details Client name *Client address *Client telephone *Client email *Patient Details Age *Breed *Colour *Sex *MMNFFNPresenting problem *Current medication *Any additional informationInsurance company (if applicable)Upload a full clinical history and any lab results Click or drag files to this area to upload. You can upload up to 7 files. Please upload individual files with the following extensions: .png, .jpg, .jpeg .doc, .docx, .pdfSubmit
