EARLSWOOD VETERINARY HOSPITAL F AX N O .
02890 657030
R
I
S
(Please complete and fax to EVH prior to the Referral Appointment Date)
*** Referring Vets **** Please advise your Clients that i t is Earlswood’s policy not to accept payment directly from insurers for referral clients. Bills are to be settled in full on pet’s discharge.
ALL clients will be expected to pay a £100.00 deposit following first consultation .
Insured Clients should bring their policy documentation and a signed Claim form with them to the first consultation which we will complete and forward to their respective Insurance Company for reimbursement directly to the Client.
To facilitate the clients prompt reimbursement from their insurer, referring Vets need to send in their own insurance claim form promptly. Insurance companies are refusing to pay ongoing referral claims until primary form from own Vets has been received.
Referring Vet’s Name
Referring Practice Name
Referring Practice Address
Referring Practice Tel Number
Referring Practice Fax No.
Referring Practice Email
Owners Name & Address
Owners Contact Telephone No.
Pet’s Name
Species, Breed, Age & Sex
Weight
Insurance Company
Your Insurance Claim Diagnosis
Please advise method of referral letter:- Fax Email Post
H ISTORY
Date of Onset of Clinical Signs
Presenting Signs
Clinical Exam details & relevant test results
193 Belmont Road, Belfast BT4 2AE Tel 02890 471361 Page 1 of 1 Rev. 4 Feb 2013