Easy Direct Referral Form (On-line)

< Back to homepage

If you would like to refer a case to Pinnacle Specialists on-line, please complete the information requested below and click “Refer Case”.

We try to do our bit for the environment and run a "paperless office" as far as possible. It would be very helpful if you were to use the online form and upload your client's details, patient's medical history and any relevant lab results onto this electronic form. If your IT system does not allow this, simply check the relevant box at the bottom of this form to indicate whether you will be sending additional information by fax or by e-mail. All referrals made on this form should be accompanied/followed on the same day by a medical history and any relevant lab results. All histories/results sent under separate cover should be clearly marked with the pet's name and the owner's surname and the date of referral, either on a fax cover sheet or in the subject line of the e-mail (as applicable).

All fields are required. If you do not know one or more of the owner contact details, please type “not known” in the relevant box.

Many thanks from the whole team at Pinnacle Specialists.

Your name:
Practice address:
Practice telephone:
Your/practice e-mail (please indicate recipient):
Owner name:
Owner address:
Owner telephone 1:
Owner telephone 2:
Owner e-mail:
Pet name:
Species & breed:
Age & gender:

Brief description of problem giving rise to referral:


Department with which appointment requested:	Internal Medicine Medical Oncology Cardiology
Urgency With Which Appointment Required (please select):	Routine Urgent

If the case is an emergency - PLEASE also phone one of our service representatives for immediate assistance.

Please Provide Any Known Insurance Details (eg. Provider, type of cover in force, exclusions on the policy, policy limits, amount spent on condition etc.)


Any Other Information You Feel is Relevant:


Please check one of the following:
I wish to upload my patient's history (see below); I will be sending my patient's history under separate cover by e-mail; I will be sending my patient's history under separate cover by fax; I will be sending my patient's history under separate cover by post

Please click here to upload your patient's medical history/lab results (.pdf or .doc files only)

Once you have fully completed this form please click the 'Refer Case' button below.